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


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Case 1 :08-cv—00328-GIVIS Document 1 Filed 05/30/2008 Page 1 of 2
AO 240 (Rev. 10/03)
DELAWARE (Rev. 4/OS)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Donald Cole
Plaintiff, APPLICATION TO PROCEED
v. WITHOUT PREPAYMEN T OF
FEES AND AFFIDAVIT
Warden Phelps, D.C.C.
Defendant(s) CASE NUMBER:03090l3358
I,Donald Cole declare that I am the (check appropriate box) {Q Qi l`
E Petitioner/Plaintiff/Movant I] Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs rmder 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? E Yes I] No (If "No" go to Question 2)
If "YES" state the place of your incarceration Delaware Correctional Center
Inmate Identification Number (Required): 00281479
Are you employed at the institution? No Do you receive any payment from the institution? No
Attack rt ledger sheet [orm the institution ot your incarceration showing. at least the gast six months ’
transactions
2. Are you currently employed? I:] Yes E 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 {rom any of the following sources?
a. Business, profession or other self-employment [I Yes IZ No
b. Rent payments, interest or dividends I:] Yes E No
c. Pensions, amruities or life insurance payments I:] Yes IZ No
d. Disability or workers compensation payments [I Yes IZ No
e. Gifts or inheritances I:] Yes IX No
f Any other sourcw E Yes [I 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. I receive money from my family every once in a while.
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MMR (Rage 1 :08-cv—00328-GIVIS Document 1 Filed 05/30/2008 Page 2 of 2
° DEl:AWAl?E (Rev. 4/05)
4. D0 you have any cash or checking or saving accounts? [I Yes IZ No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securitim, other tinancial instruments, automobiles or other
valuable property? [I Yes IZ 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.
None.
I declare under penalty of perjury that the above information is true and correct.
5 ~ ir: ~. ot QQTAX crit.
DATE SIGNATURE OF APPLICANT
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afiidavit
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 accotmts. If
you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.

Case1:08—cv-00328-GIVIS D0cument1—2 Fnled 05/30/2008 Page1 0f2

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Case 1:08-cv-00328-GMS

Document 1

Filed 05/30/2008

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Case 1:08-cv-00328-GMS

Document 1

Filed 05/30/2008

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Case 1:08-cv-00328-GMS

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Case 1:08-cv-00328-GMS

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