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


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Date: April 28, 2008
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State: Delaware
Category: District Court of Delaware
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Case 1 :08-cv-00241-JJF Document 1 Filed O4/28/2008 Page 1 of 2
AO 240 (Rev. 10/ IB)

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UNITED STATES DISTRICT COURT ele ‘ · J at *3* i iii
DI TRICT OF DELAWARE it .
S MS AER 28 Ati ‘3= IH
33 r" . · E
Plaintiff APPLICATION TO PROCEED
V. ____ WITHOUT PREPAYIVLEN T OF
6-rzM Cgué [ ble Q f g FEES AND AFFIDAVIT
Defendant(s) · 1
CASE NUMBER: ’ '
*4 ` I-,
1, EA- /12 { Q { A · M 0/ZSLQ A] declare that I am the (check appropriate box)
° ° Petitioner/Plaintiff/Movaut ° ° 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? ° Yes ° ® (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger shget iam the institution of your incarceration showing atleast the ggst six months '
transactions
2. Are you currently employed? ° ° Yes ° ®
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 l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other seltiemployment • • Yes •
b. Rent payments, interest or dividends • • Yes ·
c. Pensions, annuities or life insurance payments • • Yes • @
d. Disability or workers compensation payments • · Yes • agri!
e. Gifts or inheritances • • Yes • • 0
f. Any other sources · • Yes · QQ
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-00241-JJF Document 1 Filed O4/28/2008 Page 2 of 2
AO 240 Rzvase (Rev. 10/OB)

4. Do you have any cash or checking or savings accounts? · · Yes é· •No)
If "Ycs" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other Hnancial instruments, automobiles or other
valuable property?
® · •N¤
If "Yes" describe the property and state its value.
goo; /W»4 z¢{»4 "ZTLZ étusfé ,£Q,_,_,L"‘7l 3 (6 . ··*
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 SUPPOYL OR state NONE if applicable.
New E,
I declare under penalty of perjury that the above infomation is tmc and correct.
i* gf" éQjé£`€_£; . 7
DATE SIGNATURE OF APP ICANT
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, cxpenditu res, 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-00241-JJF

Document 1

Filed 04/28/2008

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Case 1:08-cv-00241-JJF

Document 1

Filed 04/28/2008

Page 2 of 2