A0 240 (Rev. I0/03)
DEl.AWA.RE!Rcv. 5/06)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
'TQL, H s .3 Ln]; iq , d
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
M €
Defend ant(s)
CASE NUMBER: '3\l (
I, 2 O de. [Z; Z) · S Ll Q LQ X declare that I am the (check appropriate box)
Q Petitioner/Plaintiff/Movant I:] Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs 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:
l. Are you currently incarcerated? D Yes §oNo (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identiiication Number (Required): _
Are you employed at the institution? Do you receive any payment from theinstitution?
Attach a ledger sheet [rom the institution ot your incarceration detailing all transactions gver the gust
six months.
2. Are you currently employed? D Yes w No
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.
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment /¤¤ Yes D No
b. Rent payments, interest or dividends ¤ Yes U No
c. Pensions, annuities or life insurance payments D Yes ¤ No
d. Disability or workers compensation payments El Yes ¤ No
e. Gifts or inheritances ci Yes ¤ No
tl Any other sources D Yes tj 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-00341-JJF Document 5 Filed 06/10/2008 Page 2 of 2
AO 240 Reverse (Rev I0/01)
DELAWAREtRev 5/D6! T T 4 L_1, ,
4. Do you have any cash or checking or savings accounts? E1 Yes me
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
.. · kl Yes R No
If "Yes" describe the property and state its value.
Lo ben S
/1:0/ein.; Ge ¤~<·*· é-¤~®r$
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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.
5 e Z-?
I declare under penalty of perjury that the above infomation is true and correct.
I
6 { {O; 0 Z ·—-\ .
DATE SIGNATURE OF APPLICANT
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 5
Filed 06/10/2008
Page 1 of 2
Case 1:08-cv-00341-JJF
Document 5
Filed 06/10/2008
Page 2 of 2
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