Free Order - District Court of Delaware - Delaware

Case 1 :04-cv-00419-JJF Document 127-2 Filed 06/16/2008 Page 1 of 2
AO 240 (Rev. 10/03)
DELAWARE(Rev. 5/06)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Prarnurr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: 04-419 JJF
I, declare that I am the (check appropriate box)
El Petitioner/Plaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? El Yes El No (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet [rom the institution o[ your incarceration detailing all transactions over the past
six: months.
2. Are you currently employed? El Yes El No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period
and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment D Yes U No
b. Rent payments, interest or dividends D Yes D No
c. Pensions, annuities or life insurance payments D Yes D No
d. Disability or workers compensation payments D Yes El No
e. Gifts or inheritances EJ Yes D No
f. Any other sources D Yes U No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

Case 1:04-cv-00419-JJF Document 127-2 Filed 06/16/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARE {Rev 5/062
4. Do you have any cash or checking or savings accounts? El Yes EJ No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes El No
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
I declare under penalty of perjury that the above information is true and correct.
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:04-cv-00419-JJF

Document 127-2

Filed 06/16/2008

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Case 1:04-cv-00419-JJF

Document 127-2

Filed 06/16/2008

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