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

Case 1:08-cv-00221-JJF Document 1 Filed O4/18/2008 Page 1 of 2
AU 240 (Rev 10/0])
DEL.=\WAREtRev 5l06!
\N UNITED STATES DISTRICT COURT
G DISTRICT or DELAWARE

riannrr APPLICATION TO PROCEED
_ V. _ WITHOUT PREPAYMENT OF
gfgg A//z 4 /ll/Q FEES AND AEE1DAv1T
Defendant(s)
_ CASE NUMBER:
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I, declare that I am the (check appropriate box)
51/ PetitionerfP ovant E Other
'3 22
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees €’cos(é?;_nder
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitle@ tl1?l`fel_ief
sought in the complaint/petition/motion. __,. QQ?-‘
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In support of this application, I answer the following questions under penalty of perjury: ,65
l . Are you currently incarcerated? ij Yes mi No (lf"No" go to Question 2) id
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? M Do you receive any payment from the institution? Md
Attach a ledger sheet from the institution of your incarceration detailing all transactions over the gast
six months. A
2. Are you currently employed? El Yes me
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.
b. If the answer is "NO" state the date of your last employment, the amount of your take—home
_ sala or wages and pay period and the name and address of your last employer. d
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3. In he past 12 twelve months have you received any money fro any ofthe ollowing sources? V my

a. Business, profession or other self-employment El Yes Nélo W
b. Rent payments, interest or dividends D Yes l¤/No P {ttf
c. Pensions, annuities or life insurance payments D Yes $0
d. Disability or workers compensation payments El Yes {No
e. Gifts or inheritances D Yes No
f Any other sources 12{ Yes EI Ng
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. C h l`/p 52//glgg,/7‘··
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Case 1 :08-cv-00221-JJF Document 1 Filed O4/18/2008 Page 2 of 2
AO 240 Reverse (Rev ID/OJ) T. A I i if ri I I
DELAWARE;{Rev 5/06 " ’
4. D0 you have any cash or checking or savings accounts? E1 Yes A
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, other
valuable property?
Bf Yes El No
If "Yes" describe the property and state its value. Fw
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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.
j@3iK
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-00221-JJF

Document 1

Filed 04/18/2008

Page 1 of 2

Case 1:08-cv-00221-JJF

Document 1

Filed 04/18/2008

Page 2 of 2