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

Case 1 :08-cv—00535-JAP Document 1 Filed 08/22/2008 Page 1 of 2
AO 240 (Rev I0/O3) I J A
DELAWARElRev. S/06] E;} T 7 .c—
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE W. $£,§};2 ,
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Plaintiff APPLICATION TO
V. WITHOUT PREPAYMENT OF
Cb · · Cwo/JI E ALC, FEES AND AFFIDAVIT
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CASE NUMBER: if A I
I, { QI B»·C<... Q lg g§t~> declare that I am the (check appropriate box)
Bil 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 §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitledtto the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following quest? under penalty of perjury:
l Are you currentlv incarcerated? Cl Yes No (lf "l\lo" co to Ouestion 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 gas!
sir months. {
2. Areryou currently employed? El Yes 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
s ary or wages and pz? period and the name and address of your last employer.
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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 El Yes { No
b. Rent payments, interest or dividends U Yes nf No
e. Pensions, annuities or life insurance payments D Yes cf No
d. Disability or workers compensation payments El Yes {2f No
e. Gifts or inheritances D .Yes { No
f. Any other sources 2/ 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 :08-cv—00535-JAP Document 1 Filed 08/22/2008 Page 2 of 2
AO 240 Reverse (Rev, IO/03) ·
DELAWARE ev 5/06
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4. Do y0u have any cash or checking or savings accounts? /Yes E1 No
If "Yes" state the total amount S [QO·C>O
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? M »
' - - a4r es D No `
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.
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I declare under penalty of perjury that the above infomation is true and correct.
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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 certiiied 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-00535-JAP

Document 1

Filed 08/22/2008

Page 1 of 2

Case 1:08-cv-00535-JAP

Document 1

Filed 08/22/2008

Page 2 of 2