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

Case 1 :08-cv-00420-SLR Document 1 1 Filed 08/28/2008 Page 1 of 2
f AO 240 (Rev. IO/0])
DELAWAREjRev. 5/06
— UNITED STATES DISTRICT COURT
· DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
t V. WITHOUT PREPAYMENT OF
S X; gg Mg S gg QS gt gggql Q.\ .Ot\ t FEES AND AFFIDAVIT
Defendant(s)
cAsE NUMBER: \‘_ O 95 · g \/ - \.\"3_g
I, be Q Iggy ft S gk]; Q §O Q declare that I am the (check appropriate box)
lQ/ Petitioner/Plaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, I declare that I am unable to pay thecosts of theseproceedingsand that I am entitled tothe relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questyrrder penalty of perjury:
1. Are you currently incarcerated? El Yes No (lf "No" go to Question ‘
If "YES" state the place of your incarceration GO . 5;}*
·g rr; ;z;i-nj "
Inmate Identification Number (Required): --,3 J
Are you employed at the institution? Do you receive any payment from the instittitjigorr?
Attach a ledger sheet [rom the institution ot your incarceration detailing all transactions overithe gast
six months.
2. Are you currently employed? El Yes `lgilo
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 yvages and pay period and the name and address of your last employer.
Tl] " Ogg <'\Q,\\x(\ 3. In the past I2 twelve months have you receive any money fllnm anypgge following sources? Q s Ps ·
a. Business, profession or other self-employment El Yes sf No
b. Rent payments, interest or dividends El Yes 51/ No
c. Pensions, annuities or life insurance payments El Yes 5/ No
d. Disability or workers compensation payments El Yes IJ No
e. Gifts or inheritances D Yes 15/ No
f. Any other sources El Yes IS/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.

Case 1:08-cv-00420-SLR Document 11 Filed 08/28/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/03) A '
DELAWARE tliev 5/G6!
4. Do you have any cash or. checking or savings accounts? El Yes @4%
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property:] · 5,/
» ‘ C1 Yes No
If "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.
/\/\xr poi Sec; _ NV? SK Slo" <·\ Q~o"g\ as o·5\
I declare under penalty of perjury that the above information is true and correct.
3 - 2 ! E .> Q 3 ( py
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 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-00420-SLR

Document 11

Filed 08/28/2008

Page 1 of 2

Case 1:08-cv-00420-SLR

Document 11

Filed 08/28/2008

Page 2 of 2