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

Case 1 :08-cv-00491-SLR Document 1 Filed 08/06/2008 Page 1 of 2
§>A() 240 (Rev. 10/03) __
UNITED STATES DISTRICT COURT :1 ai
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District of Delaware Gi)
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STATE OF DELAWARE AND INDYMAC BANK, -¤
FSB: Fmcnous Fontarew STATES APPLICATION TO PROCEED 3*
Plaintiff WITHOUT PREPAYMENT OF Q? by
V FEES AND AFFIDAVIT cj D
phillip-allen: family dye non—corporate
Gmltv cAsE NUMBER: . O 8 ` A l
Defendant
I, phimpalleni declare that I am the (check appropriate box)
2petitioner/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 §l915 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? lj Yes I No (If "No," go to Part 2)
If "Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? [I Yes 5 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. (List both gross and net salary.)
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 I] Yes fi No
b. Rent payments, interest or dividends I] Yes IZ No
c. Pensions, annuities or life insurance payments I] Yes IZ] No
d. Disability or workers compensation payments EI Yes H No
e. Gifts or inheritances III Yes E No
f. Any other sources [Il Yes Ti No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.

Case 1 :08-cv-00491-SLR Document 1 Filed 08/06/2008 Page 2 of 2
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3 (g). Please do not confuse phiIIip—alIen: family dye with the corporation known as PHILLIP A DYE.
4. Do you have any cash or checking or savings accounts? I] Yes IZ] No
If "Yes," state the total amotmt. ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? [I Yes Z 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. (If children are dependents, please refer to them by their initials)
I declare under penalty of perjury that the above information is true and correct.
August 6, 2008 — M-<-=- t
Date Signature of Applicant
NOTICE T 0 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-00491-SLR

Document 1

Filed 08/06/2008

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Case 1:08-cv-00491-SLR

Document 1

Filed 08/06/2008

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