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

Case 1 :08-cv-00449-JJF Document 1 Filed 07/18/2008 Page 1 of 2
AO 240 (Rev. 10/(X3)
DELAWARE {Rev. 4/05
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
Kjm CL .V. WITHOUT PREPAYNIENT OF
VW E, - Enom Q ig FEES AND AFFIDAVIT
Defendant(s) A g V, I G
CASE NUMBER: O 1`‘‘ li "‘ "’
I, TT-I ‘ ·e l tf- declare that I am the (check appropriate box)
Petitioner aintiffH\/lovant ° ° Other
___________,.........-»»-*
in the above-entitled proceeding; that in support of my request to proceed without prep ymen o l is er P
28 USC §l9l5, I declare that I am unable to pay the costs ofthese proceedings and • at I . s · · c : : ’* : ‘: `
sought in the complaint/petition/motion.
_ JUL I 8 2008
I rt f th` lication, I answer the followin uestions der penalty of perju : 5 . . . . .. ,
H Supp° ° ls app g q K u.s. uisrmcr cou t
l. Are you currently incarcerated? ° Yes ° o (If "No" goto » - ·1i€Ii' DELAW .
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 Qom the institution of your incarceration showing at least the gast six months ’
transactions |/
2. Are you currently employed? ° ° Yes ° No
a. If the answer is "YES" state the amount of you ta e-ho salary r wages and pay riod a • .
and give the name and address of your employ%i ·-/31 Elf `i§rz,¤t4L.·’ D MJX <. I
b. If the answer 1S "NO" state the date of your last employment, the amount of your take-home jqq -7 I
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 •l\%No
b. Rent payments, interest or dividends • • Yes 1/No
c. Pensions, annuities or life insurance payments · · Yes /40
d. Disability or workers compensation payments · · Yes · N
e. Gifts or inheritances · · Yes · vi£
f. Any other sources •\/ Yes · · No
If the answer to any of the above is "YES" describe each e oneynand state the amount
received AND what you expect you will continue to rec r ° {,0*-(K

Case 1 :08-cv-00449-JJF Document 1 Filed 07/18/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/ 03)
DELAWARE Rev. 4/U5! i 1. _
4. Do you have any cash or checking or savings accounts? • Ng • •No
,9
If "Yes" state the total amount $ 7g·
5. Do you own any real estate, stocks, bonds, securities, other financial instruments automobiles or other
valuable property? /
• • gs • •NO
If "Yes" describe the property and state its value. Q
GM lz.-• mat,. $/ —=e·¤·
Jl J I
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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1 declare under penalty of perjury th t the above infomation is true and correct.
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 certified by the appropriate institutional
officer showingall receipts, expenditures, and balances during the last six months in your institutional accounts.
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:08-cv-00449-JJF

Document 1

Filed 07/18/2008

Page 1 of 2

Case 1:08-cv-00449-JJF

Document 1

Filed 07/18/2008

Page 2 of 2