‘ so 1e e en, -
AO 240 (Rev. 10/03) W :;_;,,_.,»»·~»¤-*"“" t ,
DELAWARE Rev. 4 05) ["` 2
= ti
. . , - 6 200% ;
UNITED STATES DISTRICT CO . ' Tg Vw lp
DISTRICT OF DELAWARE I. E g
. I ’
TX-`o\,s E. l'*’\r\\e,(`
Sg.,,>\{.lT,_1i,,q- Pramiirr mess, <>, ;aw>\tt.~; APPLICATION TO PROCEED
ceer ¤»·r.~Q»_ v. rjrj~_i¤·' ,§§~*·~~·*i WITHOUT PREPAYMENT OF
EE"] §j,,$°»;$f E\',,!,; _t— é 2}** `*°`“§<£D§§ ,,_i\; . FEES AND AFFIDAVIT
Defendant(s)
class NUMBER: 0 8 ·— “ T ‘
I, 3_¤\-tb E-. Y"\`i $\-LC · declare that I am the (check appropriate box)
; ° Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? °)(Wes ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration D°·\<>~\>¤~‘< Q¤<<
Are you employed at the institution? ,/;l° Do you receive any payment from the institution? Q 0
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast sbt months '
transactions (
2. Are you currently employed? ° ° Yes ° No
a. If the answer is "YES" state the amount of your take~home salary or wages and pay period a
and give the name and address of your employer.
ar If the answer is "NO" state the date of your last employment, the amount of your take~home 2 OO; _
salary or wages and pay period and the name and address of your last employer. 3*,,,30 t»¤·7i I 0/ \_, K
#13.cv 5o;.sex\E.~»3 nw
3. In the past 12 twelve months have you received any money from any ofthe following sources? I’]"`°` o`
a. Business, profession or other self-employment · · Yes N No
b. Rent payments, interest or dividends • · Yes No
c. Pensions, annuities or life insurance payments _ · • Yes · No .
d. Disability or workers compensation payments A · • Yes 94 No
e. Gifts or inheritances · · Yes % No
f. Any other sources Yes • · No
csi S
lf the answer to any of the above is "YES." describe each source of money and statethe amount wko QN
received AND what you expect you will continue to receive. Q Us m ecxr r~\ U M .S€Qv Y x \ si)
I
Case 1 :08-cv-00271-JJF Document 1 Filed 05/06/2008 Page 2 of 2
AO 240 Reverse (Rev, 10/03) l
DELAWAREtRev. 4/OS!
;¤~r’\'l\\|$ Selma mg moryhl wps I q,,wo\}\ jg -\~p <;oM·o`»‘f.l·M‘7 $0* `\\€*’\
Més {RQ <>~ pe
/000 o»>Bx p€¤\§& 30;}; gw A M; lm 5 e Xrke -(§°Y< $°" ’t‘*¤€—*"\
dhicg I""“ °\\` AOVG OQ N J 0 I (xg,-\\» gx <(,\» +0 b€- j°·`\A')/ij OA)! M0r>{7
. P
aw tl me r ¤ ¤.¤ ·
4. Do you have any cash or checking or savings accounts? • • Yes %No
lf "Yes" state the total amount $
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.
'I 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.
0,38. .
I declare under penalty of perjury that the above information is true and correct.
5/ / O ‘t> =
D E SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit l
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
ofticer 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-00271-JJF Document 1-2 Filed 05/06/2008 Pagei?1 ef 1; 7 '
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEM ORAND UM
To.- ( 24 .5 It gg `[ [Q sB1#.· gpgfgggggfw
FROM: Stacy Shane, Support Services Secretary g E
RE: 6 Months Account Statement
. MAY — 6 2000
DA TE: ; it Q /i QI gg ` ‘ US...§.....-.. -
¤¤ér ¤6 / # s 1;*;£#E¤=¤E
Attached are co ies of your inmate account statement for the mont of
{ figgjgggg [ to C}! >> .
The following indicates the average daily balances.
MONTH AVERAGE DAILY BALANcE
` e»©’
.00040/41 _
Average daily balances/6 months: { O Q
Attachments
cc.- Fzle §@¤4JLiiZQ ML;/»
T Allow **/*1/M
Case 1:08-cv-00271-JJF
Document 1
Filed 05/06/2008
Page 1 of 2
Case 1:08-cv-00271-JJF
Document 1
Filed 05/06/2008
Page 2 of 2
Case 1:08-cv-00271-JJF
Document 1-2
Filed 05/06/2008
Page 1 of 1
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms