Free Motion for Leave to Proceed in forma pauperis - District Court of Delaware - Delaware

Case 1 :08-cv-00540-SLR Document 1 Filed 08/25/2008 Page 1 of 2
AO 240 (Rev. I0/O3)
DELAWA.REtRev. 4/05]
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riaiuatr APPLICATION TO PROCEED
_ I VW _ _ WITHOUT PREPAYIVIENT OF
Ut) ILM INCFJI//U tlOU5ll»/6 Alt/T/+(W!H‘t FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER; _ 0 8 — 5 4 0
I, L L <_ cx rel lZlCl\lIJUD declare that I am the (check appropriate box)
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W Petitioner/Plaintiff/Movant Cl Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, 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:
l Are you currently incarcerated'? Cl Yes IE/No l'lf"No" go to Question 2)
If "YES" state the place of your incarceration `
Inmate Identification Number (Required): {gl
Are you employed at the institution? N0 Do you receive any payment from the institution? N O
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months ’
transactions
2. Are you currently employed? El Yes IZ/No
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a
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 I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment EI Yes IY No
b. Rent payments, interest or dividends El Yes EV No
c. Pensions, annuities or life insurance payments D Yes Ur No
d. Disability or workers compensation payments E1 Yes EV No
e. Gifts or inheritances D Yes B/No
f. Any other sources 45/ Yes U No
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If the answer to any of the above is "YES" describe each source of money and state the ount
received AND what you expect you will continue to receive.

Case 1:08-cv-00540-SLR Document 1 Filed 08/25/2008 Page 2 of 2
AO 240 Reverse (Rev. I0/03)
DELAWAR.ElRev. 4/05
4. Do you have any cash or checking or savings accounts? D Yes *%,0
If"Yes" state the total amount $5 b I
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ~
J Yes glo
If "Yes" describe the property and state its value.
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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.
Nomé
I declare under penalty of perjury that the above information is true and correct. J 02,
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ATE 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 1:08-cv-00540-SLR

Document 1

Filed 08/25/2008

Page 1 of 2

Case 1:08-cv-00540-SLR

Document 1

Filed 08/25/2008

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