` AO 240 (Rev. l0/03)
DELAWAREt!b:v 5/06)
. it ’ i"“‘:;:t
UNITED STATES DISTRICT COURT · » ~Y·
DISTRICT OF DELAWARE { I. ~_ i M FH gt: 39
Ogcfo l.»50~» 4, mo»lO/lg
Piaimirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
Hgnqi gl P,,, H [(,0,, jq fe; reiiwg bepwrmewt FEES AND AFFIDAVIT
Defendant(s) Ilrfe/¤~9¤**·$ , pf) {M if N Q 5
CASE NUMBER: `r’ Y
I, ( (gf § O \\’l../'\'5
in the above-entitled proceeding; that in support of my request to proceed without prepayment of feesgor 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 Q/No (If "No" go to Questioni 2)
If "YES" state the place of your incarceration N/Q _f
Inmate Identiiieation Number (Required): M M
Are you employed at the institution? N Do you receive any payment from the institution? _}j[g
Attach a ledger sheet [rom the institution of your incarceration detailing all transactions over the gast
sir months.
2. Are you currently employed? D Yes mile
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. V/ft
b. If the answer is "NO" state the date of your last employment, the amount of your take-home ik
salary or _yvages ancgay period and the name and address of your last employer ..T6*V'·’ · *90 °2 OO7
jay, ‘ »JL(/7 /L·l§_ rpg; [Nik Qaagevatf 'Z?/JJ, ‘P(»r) lzsalefe ir-; Pa /9 I Z‘/
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment U Yes if No
b. Rent payments, interest or dividends D Yes Z No
c. Pensions, annuities or life insurance payments U Yes J2’ No
d. Disability or workers compensation payments 6 Yes E1 No
e. Gifts or inheritances m Yes Q/ No
f. Any other sources I3} Yes KT No
If the answer to any of the above is "YES" describe each so e of money and state the amount _ gb,
received AND what you expect you will continue to receivew@, L:). Cl P. (O (Trice at ¢»·{;’2l°é{‘iM(£€mFé*5k
0 O
Oczb Month)? _;,LmSe.,»,,_ [Q,_t,,({_ [ KJ
i
(Eh <`0¤i.rc.¤ 0*. .—..-j.¢»,`.`. we I" U A [Limb
Case 1 :08-cv—00280-GIVIS Document 1 Filed 05/14/2008 Page 2 of 2
A0 240 Reverse (Rev. 10/03)
4. D0 you have any cash or checking or savings accounts? if Yes D No
Cl M <>°
If "Yes" state the total amount $ /
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? V
;~` gf Yes D No
If "Yes" describe the property and state its vglue. 00 Da M0r+,,jgA {Z, p J'! 5 Q, ¤¢>¢>·‘“"'
._ i O { ·-'
— - r /v¤» ’·· . ,2 i
M r< FM Mer $,/5/,,.. . =~ com ’¢4»»>~ ·° °" ‘
Zoe; Fark `lZ¤»•"j*?•’
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.
(,.lE£{l¢rw·. -· ,§pDHQE Q
I declare under penalty of perjury that the above information is true and correct.
céltglltsagj ( ,40./Ze-â€;77?@
DAT 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. _ A
Case 1:08-cv-00280-GMS
Document 1
Filed 05/14/2008
Page 1 of 2
Case 1:08-cv-00280-GMS
Document 1
Filed 05/14/2008
Page 2 of 2
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms