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A0 240(Rev l0/03)
DEL,·\w.-\REi’Rev 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
irvr vkhgq fb. lg gfbiif
riamrrr APPLICATION TO PROCEED
Q _ V. WITHOUT PREPAYMENT OF
KQQQE pity I is FEES AND AFFIDAVIT
fendarrt(s) _
/ CASE NUMBER: i` Zi. I
I, D [ ( (gd bib I Q . Q; Q [l ;· declare that I am the (check appropriate box)
° ° Petitioner/Piaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §I9l5, 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? {Q ° °No (If "No" go to Question 2)
fi , . or
If "YES" state the place of your incarceration W/L)f’I*/L QH! U /L/YQ 2 ( Q
Inmate Identification Number (Required): l Q ( 2
. . . . . . . {L20
Are you employed at the institution? QU Do you receive any payment from the institution?
Attach a ledger sheet {rom the institution of vour incarceration showing at [east the past sir mont/is'
transactions /_T_
V`·.`\;`
2. Are you currently employed? ° ° Yes by
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 tal
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · • Yes gm
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-00247-SLR Document 1 Filed 04/29/2008 Page 2 of 2
-\O 140 Reverse (Rev I0/03)
DELAWARE(Rev 4/05)
4. D0 you have any cash or checking or savings accounts? • • Yes • ‘ ry
lf "Yes" state the total amount S {/’/W
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• • Yes &• •l`·‘lo
,/
If "Yes" describe the property and state its value.
/\/ if .
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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.
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I declare under penalty of perjury that the above infomation is true and correct.
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DAT SIGNATU OF PLlCAi T ·
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating aU 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-00247-SLR
Document 1
Filed 04/29/2008
Page 1 of 2
Case 1:08-cv-00247-SLR
Document 1
Filed 04/29/2008
Page 2 of 2
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