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

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DISTRICT OF
plaintiff APRLICATION TO PROCEED
- _ WITHOUT PREPAYMEN T OF
iilxllm W\°ul\l&L FEES AND AFFIDAVIT I
V.
Defendant CASE NUMBER: ` [ll 3
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I, Tflgjl Hyg { declare that I am the (check appropriate box)
E petitioner/plaintiff/movant E] other
inthe above—entit|ed proceeding; that in support of my request to proceed witho ph · · * · · _ r costs ·
under 28 USC. §1915 I declare that I am unable to pay the costs of these proc din s and that I am e ’ ed
to the relief sought in the compIaint/petition/motion. A JUL 1 0 2008 .
_ _ _ _ _ . i nr
In support of this application, I answer the following questions under penalty 5-- J · ICTOFDELAWAI? '\_ N A ~
1. Are you currently incarcerated? le] Yes I;] No (If "l\lo" go to Part 2)
lf “Yes" state the place of your incarceration S, I S, gg ggggiopjgligél l)§S,g,,§§gj
Are you employed at the institution? SQ;) Do you receive any payment from the institution? Q O
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? lj 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 our take—home salary or
· wages and pay period and the name and address of your last employer. IQQ (NN Y\ Ogg!
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3. In the past 12 twelve months have your received any money ffom any of the following sources?
a. Business, profession or other self—empIoyment I:] Yes No
b. Rent payments, interest or dividends I:] Yes E No
c. Pensions, annuities or life insurance payments I;] Yes [Q No
d. Disability or workers compensation payments I:] Yes Q No
e. Gifts or inheritances I:] Yes Q No
f. Any other sources I;] Yes No
lfthe answer to any ofthe 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—00443-JJF Document 1 Filed 07/16/2008 Page 2 of 2
AO 240 (Flev. 9/96) (Reverse)
4. Do you have any cash or checking or savings accounts? El)/es til No
lf "Yes" state the total amount.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? lj Yes E No
lf "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. t,\\rIrx( tg \'y_Q·{ OQ ;~M§QWmQ B
I declare under penalty of perjury that the above information is true and correct.
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DATE SIGNATURE OF APPLICANT
NOTICE TO PRISONER: A Prisoner seeking to proceed IFP shall submit an affidavit stating all assets.
ln 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. lfyou
have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:08-cv-00443-JJF

Document 1

Filed 07/16/2008

Page 1 of 2

Case 1:08-cv-00443-JJF

Document 1

Filed 07/16/2008

Page 2 of 2