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

r Case 1 :08-cv—00432-GIVIS Document 2 Filed 03/12/2008 Page 1 of 2
eaozau (Rev. rum)
UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT District of NDRTl—l CAROLINA
Burl A. Howell, 207 Dobbs Dr., LaGrange, NC
28551 APPLICATION TO Pnoceen FILED
Plaintiff WTTHOUT PREPAYMENT OF
V, FEES AND AFFIDAVIT MAR 1 2 ZODB
slate er Delaware B'§'§`§§,g|g].#g%5»;lE;_L g
CASE NUMBER: __—"""` It "i"
Defendant
I. Burl A HOWEU declare that I am the (check appropriate box)
G petitioner/plainti G other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §l 915 I declare that I am unable to pay the costs of these proceedings and that Iam 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? G Yes (If "No," go to Part 2)
If "Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? G Yes
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 your take-home salary or wages
and pay period and the name and address of your last employer.
Nov. 1997, don't remember amount of wages or pay period, Mini Maids of Bethany Beach, Delaware
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment G Yes G No
b. Rent payments, interest or dividends G Yes G No
c. Pensions, annuities or life insurance payments G Yes G No
d. Disability or workers compensation payments G No
e. Gifts or inheritances es G No
f. Any other sources G Yes G No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.

° Case 1:08-cv—00432-Gl\/IS Document 2 Filed 03/12/2008 Page 2 of 2
AO 240 Reverse (Rev. 10;*03)
Social Security Disability Income of $1 ,057.00 per month expected to continue indefinitely.
4. Do you have any cash or checking or savings accounts? G Yes
If “Yes," state the total amount.
5. Do you own any real , ocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? G Yes ,- G No
If “Yes," describe the property and state its value.
Home [tenant in entireties with wife] at 207 Dobbs, Dr., LaGrange, NC 28551 valued at $164,280.00
Car [tenant in entireties with wife] approximate trade in value $10,000.00
Truck [tenant in entireties with wife] approximately trade in value $1,500.00
Other household furnishings and clothing [tenant in entireties with wife] approximate value $1,500.00
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.
Alice A. Howell, Wife, I contribute 100% of support
I declare under penalty of perjury that the above information is true and correct.
M!
3/6/2008 Q7
Date Signature of Applicant
NOTICE 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. lf you have
multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each
account.


Case 1:08-cv-00432-GMS

Document 2

Filed 03/12/2008

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Case 1:08-cv-00432-GMS

Document 2

Filed 03/12/2008

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