AO240(Rev. 10/03) »l_' U Q ·· · ,. M vm
DELAWARE Rev. 4/05) l '~ ‘· I , ' ' ' Rift;
r UNITED STATES DIS'l{RI(i'TliCUURT lt 5;.,
DISTRICT OF DELAWARE
laintiff APPLICATION TO PROCEED
_ V. WITHOUT PREPAYMENT OF
FEES AND AEE1DAv1T
, efendant(s {High ‘ LC Oppif
-4 5 /31 / CASE NUMBER: W F Q
L ‘ O declare that I am the (check appropriate box)
°X° Petitioner/Plaintiff/Movant ° ° 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? °X°{es ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration K i 1
Inmate Identification Number (Required):
Are you employed at the institution? O Do you receive any payment from the institution? C)
Attach a ledger sheet from the institution of your incarceration showing at least the gast six months '
transactions
2. Are you currently employed? ° ° Yes ° 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 • · Yes • • No
b. Rent payments, interest or dividends • • Yes • • No
c. Pensions, annuities or life insurance payments • • Yes · • No
d. Disability or workers compensation payments · • Yes • • No
e. Gifts or inheritances • · Yes • · No
f. Any other sources · • Yes · · 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-00279-JJF Document 1 Filed 05/13/2008 Page 2 of 4
AO 240 Reverse (Rev 10/03)
DELAWARE Rev. 4/OS!
4. Do you have any cash or checking or savings accounts? · · 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?
• · Yes • •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.
I declare under penalty of perjury that the above information is true and correct.
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 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—00279-JJF Document 1 Filed 05/13/2008 Page 3 of 4
DELAWARE CORRECTIONAL CENTER
INMATE REQUEST FOR CERTIFIED TRUST FUND
ACCOUNT STATEMENT OF PRIOR SIX—MONTH PERIOD
TO: Mrs. Tonya Smith
Support Services Manager DATE: .
Delaware Correctional Center
Smyma, Delaware 19977
FROM:
Inmate Name (Please Print Name) SBI #
A --- I HEREBY CERTIFY ---
Pursuant to the Prison Litigation Reform Act, 28 U.S.C. 1915 (a)(2),
Effective April 26, 1996, I am requesting a certified Statement of my Institution Trust
Fund Account for the previous six-month period. Please forward same to me.
Signature
(28 U.S.C. 1746 and 18 U.S.C. 1621)
Case 1 :08-cv-00279-JJF Document 1 Filed 05/13/2008 Page 4 of 4
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