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AO 240 (Rev. 10/03) x
DELAWARE Rev. 4 05 1
{ AUG - 5 2000 g
UNITED STATES DISTRICT COURT r _
DISTRICT OF DELAWARE l...-»--·r1"""‘ E
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Iwréi /lRa8a‘ét$·Dqp~/y Azraarrrrnrrrr .6 O F2/raw ·C%4a{' APPLICATION TO Pnocuun
Hullf llhw /WW¤¥†‘(>¤VéFM>¢€ V. V _%g4,,_·pjp, WITHOUT PREPAYMENT OF
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C/W/» DH’VB¢’@7·‘/;l7`/Zéggg g5IZJ€AAL g;5'T /Q1B[¢i:’> (jeg FEES AND AFFIDAVIT
Defendant(s) ... 8 B
p CASE NUMBER: · O 8 A
I, Q/¢%76;’ [7é/{A? [ declare that I am the (check appropriate box)
° ° Petitioner/Plaintiff/Movant ° ° Other
"in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under H
28 USC §l9l5, 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? °)/°{es ° °No (If "No" goto Question 2)
If "YES" state the place of your incarceration ;2?/4zuLQ/¢’5- &Ji€€éC'-{0/1/H4
Inmate Identification Number (Required): 56I`# 0052 02000
Are you employed at the institution? @0 Do you receive any payment from the institution? /00
Attach a ledger sheet from the institution of your incarceration showing at least the past six mont/ts'
transactions
2. Are you currently employed? 674Yes ° No
a. If the answer is "YES" state the amount of your take-home salary or wages an pay period a _ â€
3 d `ve the name and address of your em loyer. ,Wé@.€ /776gO /q? /%v16}¢,{5 / 98/’/tffgfvé S T
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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 l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · • Yes • No
b. Rent payments, interest or dividends • • Yes • No
c. Pensions, annuities or life insurance payments • · Yes jf No
d. Disability or workers compensation payments • • Yes No
e. Gifts or inheritances • • Yes • • No
f. Any other sources • · Yes • 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-00486-SLR Document 1 Filed 08/05/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/ O3)
DELAWARE Rev 4/OS
4. Do you have any cash or checking or savings accounts? • • Yes 9
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• • Yes "]LNo
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 Eapplicable.
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I declare under penalty of perjury that the above information is true and correct.
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D TE SIGNAT F 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—00486-SLR Document 1-2 Filed 08/05/2008 Page 1 of 2
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DELA WARE C ORRE C T I ONAL CE T RAUG - *5 2008 j
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FROM; /}7g,rc,e/J c s l/m..1./A)
RE: 6 Months Account Statement
DATE: Ugg gg Joog
Attached are copies ofyour inmate account statementfor the months of
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Thefollowing indicates the average daily balances.
MONTH A VERA GE D/41; Y BALANcE
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Average daily balances/6 months: { 3 . gé
Attachments -
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Case 1:08-cv-00486-SLR
Document 1
Filed 08/05/2008
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Case 1:08-cv-00486-SLR
Document 1
Filed 08/05/2008
Page 2 of 2
Case 1:08-cv-00486-SLR
Document 1-2
Filed 08/05/2008
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Case 1:08-cv-00486-SLR
Document 1-2
Filed 08/05/2008
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