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

Case 1 :08-cv—OO403-GIVIS Docvnrit 1 Filed 07/O2/2008 Page 1 of 2
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AO 240 (Rev. ‘10/03)
DELAWARE Rev. 4 05 .
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Frank G. Clark, III
Piaimlrr APPLICATION TO PROCEED
Michael ASIZFUGVI Commi $$1 oner WITHOUT PREPAYMENT ’l*i‘?E
Social Sec uri ty, Administration FEES AND AFFIDAVIT }_f,Y
Defendant(s) J1 Q rg'-
CASE NUMBER: r gi
P O , N -:1;
I, VE fl V / 6 / - declare that I am the (check appropriate bc?}
R Petitioner/Plaintiff/Movant I] Other I}? -
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in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or cost‘s\under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am 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? I:-I Yes Im No (If "No" go to Question 2)
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? I:-I Yes IZ No
a. If the 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. 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.
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 El Yes III No
b. Rent payments, interest or dividends El Yes U6 No
c. Pensions, annuities or life insurance payments El Yes QI No
d. Disability or workers compensation payments El Yes ul No
e. Gifts or inheritances E1 Yes Z No
f. Any other sources El Yes jd 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—OO403-GIVIS Document 1 Filed 07/O2/2008 Page 2 of 2
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AO 240 Reverse (Rev. 10/03)
DELAWARE lRev. 4{O5
4. Do you have any cash or checking or savings accounts? E1 Yes § No
If "Yes" state the total amount S __
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
E1 Yes j 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 cgribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above information is tr e and correct. _ “
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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 you r 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-00403-GMS

Document 1

Filed 07/02/2008

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Case 1:08-cv-00403-GMS

Document 1

Filed 07/02/2008

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