AO 240(Rev. ID/O3)
DELAWARE Rev. 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE (
Brihlin? Adm, Wi/liqm /)_
Piaimirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
.i%£é,; of gm om gbqu? La dy - FEES AND AEEroAv1T_
D¢t"<>¤
I, Vi/17//,0/•~ Eg {gf QQ %éig!D declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° Other O E
in the above-entitled proceeding; that in support of my request to proceed without pre . e . w - :;,; 4 V
_ 28 USC §I9I5, I declare that I am unable to pay the costs of these proceedings and i at I am e t g- •?_. =iI€-
sought in the complaint/petition/motion. I I
JUL I 5 ZODB Q
In suppon ofthis application, I answer the following questions under penalty of perju , : ‘
I. Are you currently incarcerated? ° °Yes ° w (If "No" go to uesti P}¥ l;Ab§
If "YES" state the place of your incarceration
Inmate Identification Number (Required): _
Are you employed at the institution? K Do you receive any payment from the institution? 6
Attach a ledger sheet from the institution of your incarceration showing at least the gas! six months '
_ . transactions
2. Are you currently employed? ° ° Yes ° @
a. Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer.
b. Ifthe answer is "NO" state the date of your last employment, the amount of your tal
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · · Yes • @
b. Rent payments, interest or dividends · · Yes • •
c. Pensions, annuities or life insurance payments · · Yes • ·
d. Disability or workers compensation payments · • Yes • •
e. Gifts or inheritances · • Yes ·
f. Any other sources • · Yes • @
Ifthe 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-00436-JJF Document 1 Filed 07/15/2008 Page 2 of 3
AO 240 Reverse (Rev. 10/03)
DELAWARE Rev. 4/05)
4. D0 you have any cash or checking or savings accounts? • · ·No
If "Yes" state the total amount $ 3 . O L
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
· · Yes W
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, OR state NONE if applicable.
/\/ on iz,
I declare under penalty of perjury that the above information is true and correct.
7/11/Oli bV,ZWJ?@%
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afiidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
ofiicer 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 certiiied
statement of each account.
†Case 1:08—cv—00436-JJF Document 1 Filed 07/15/2008 Page 3 of C}
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Case 1:08-cv-00436-JJF
Document 1
Filed 07/15/2008
Page 1 of 3
Case 1:08-cv-00436-JJF
Document 1
Filed 07/15/2008
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Case 1:08-cv-00436-JJF
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Filed 07/15/2008
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