AO 240 (Rev I0/03)
DELAWAREtRev. 5/06
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff 9 APPLICATION TO PROCEED
V. WITHOUT PREPAYMEN T OF
Jl/Z hg [EIL ( ,2,;;; 7; ,€4&7¤l9 FEES AND AFFIDAVIT
Defendant(s) ( .0 l$`+‘l¢¢‘l ‘•*"H U? li`? 0 ` C V-I do 3 9/
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I, / declare t atl am the (clieck appropriate box)
i2/ Petitioner/Plaintiff/Movant Ei Other __) _
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in the above-entitled proceeding; that in support of my request to proceed without prepayment of;;es oigpests under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am ermitled relief
sought in the complaint/petition/motion. Q
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In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? El Yes lm/No (If "No" go to Question 2) (:33
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 [rom the institution of your incarceration detailing all transactions over the gas!
six months. b U_]/ 5 ;g,i\
2. Are you cyrrently employed? M Yes El No r '
OU S/(LK $' a. If the answer is "YES" state the amount of your take-home salary or wages and pay period 9%* will
and give the name and address of your employer. _ · I Af {H g U
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b. If the answer is "NO" state the date of your last employment, the amount of your take-home @7 lr
salary or wages and pay period and the name and address of your last employer. 441
3. In the past 12 twelve months have you received any money from any of the following sources?
(M, TH. vS"~# MVA ,(·;
a. Business, profession or other self-employment ll/ Yes D No
b. Rent payments, interest or dividends lll Yes}! 97~°†Ei No
c. Pensions, annuities or life ifismahce payments B/ Yes [M0 El No
d. Disability or workers compensation payments E1 Yes IV No
e. Gifts or inheritances El Yes ¤/ No
f. Any other sources [V Yes Faq; » El No
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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. #@0 <>
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Case 1:08—cv—00341-JJF Document 8 Filed 06/19/2008 Page 2 of 2
AO 240 Reverse (Rev. l0/03)
DELAWARE {Bev 5/062
4. · Do you have any cash or checking or savings accounts'? ljé D No
lf"Yes" state the total amount $ O t/ ll y,/6 '
a r z g ati 0
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? J o _
AY Yes El No »
If "Yes" describe the property and state its value.
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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.
I declare under penalty of perjury that the above information is true and correct.
(é' [ 7* O 8 r
DATE SIG. ATURE OF AP IC
NOTE T0 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-00341-JJF
Document 8
Filed 06/19/2008
Page 1 of 2
Case 1:08-cv-00341-JJF
Document 8
Filed 06/19/2008
Page 2 of 2
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