AO 240 (Rev 10/03)
DELAWARElRev. 5/06
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
U ../ _ gz?
O ‘ Cf mq? ' ei;
Piamurr APPLICATION TO PRQCEIQ)
V. WITHOUT PREPAYMQENTWQE
{2 [ 1. 1; ll Q J pi r· O l Qtrr,:£·,;. D S. g C,/,\ FEES AND AFFIDA'VII§i§£
Defendant(s) Cir; gl
CASE NUMBER: 9% — Llg 9 _i.‘iLZ`
r) _ __, . A `. 'éji
I, Qijor l Cl 6-, ; l Oh):/lbcpij declare that I am the (check ap§ropriate. box)
El Petitione ovant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9I5,NI__declare that I am unable to pay the costs of these proceedingsand that I am entitled to the relief
sought in the etition/motion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? Cl Yes we (If "No" go to Question 2)
If "YES" state the place of your incarceration p< »
Inmate Identification Number (Required): Qi .
Are you employed at the institution? Mg Do you receive any payment from the institution? /l/(5
Attach a ledger sheet [rom the institution of your incarceration detailing all transactions over the gast
six months. N [XX
2. Are you currently employed? El Yes Em
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. Mr QQ
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
Q (»%( V f salary or wages and pay period and the gmc a% address of your last employer.
°` ‘â€â€˜Â°â€™â€”‘/‘ C €· Bl AEG jimg Z 50., ` 7 0oe<2l<%< CH/4 `7E+/¤a{t ww .De /?5·q;—
3. In the past 12 twelv onths have you received any money from any f the following sources?
a. Business, profession or other self-employment El Yes I3!/No
b. Rent payments, interest or dividends U Yes E1/No
c. Pensions, annuities or life insurance payments El Yes 13/No
d. Disability or workers compensation payments ¤ Yes Q/No
e. Gifts or inheritances Cl Yes E1/No
f. Any other sources D Yes El/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. M 0<
Case 1 :08-cv-00479-JJF Document 5 Filed 08/07/2008 Page 2 of 2
AO 240 Reverse (Rev. I0/03)
DELAWARE Sliev S/062
4. D0 you have any cash or checking or savings accounts? El Yes l3/l
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
l »``' = [ El Yes EQ/{
If "Yes" describe the roperty and state its value.
P N » z\ _
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. A
. { f
I declare under penalty of perjury that the above information is true and correct.
§_ 7 M O QZ Q;
DATE SIGNA RE 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-00479-JJF
Document 5
Filed 08/07/2008
Page 1 of 2
Case 1:08-cv-00479-JJF
Document 5
Filed 08/07/2008
Page 2 of 2
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms