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

Case 1 :08-cv-00143-SLR Document 1 Filed O3/11/2008 |?age_1 of 2 _
AO 240 [Rev. lUl0Il)
DELAWARE (Rev. SIUG)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
lll gm, a L, Mg oro
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
gg Q {ge FEES AND AFFIDAVIT
Defe dant(s)
CASE NUMBER: O 8 ·· 1 A 3
l, it Iggy, Q , Q QQLQ: declare that l am the (check appropriate box)
W Petitioneri’Plaintiff`/I\/[ovant El Other
in the above-entitled proceeding; that in support of myrequest to proceed__without prepayment of fees or costs under __
E 28 USC §l9l5, 1 declare:that l am unableto pay the costs of these proceedings and thatl am. entitled tothe relief . ‘
sought in the complaindpetition/motion.
ln support of this application, answer the following questions under penalty of perjury:
1. Are you currentlylincarcerated? _ El Yes E60 (lf "No" go to Question 2);
If "YES" state the place of your incarceration LQ Qgg
`(`1 -.. 3* QQ
Inmate Identification Number (Required): 1; t;—— tg.;
_ _ . .. at ·1.¤ ”‘* F5;.
Are you employed at the institution? ite Do you receive any payment from the institution? [lg
Attach a ledger sheet from tlze institution of your incarceration detailing all transactions over the gast .
six months. t _ ‘
2. Are you currentlyteniployed? - El Yes EQ "‘ "
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
salary or wages and pay period and the name and address of your last employer. _ (_,U[lru t}l@'Z”`”"
[-1-ilfli l-‘?>:9—O0-l QDQOOQBY me · 5‘l‘EpiC‘5» E'>&=•Ll’0 &l’l¢0|"&I QE,.
3. In the pas l2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other se]f—employment El Yes gl/No
b. Rent payments, interest or dividends El Yes El/No
c. Pensions, annuities or life insurance payments El Yes 43*2/ No
d. Disability or workers compensation payments tl Yes yo
e. Gifts or inheritances El Yes No
f. Any other sources D/Y es in No
If the answer to any of the above is "YES" describe each source of money and state the amount R if
received AND what ou expect ou will continue to receive. , 5 · I Sea; {47 Pu! mgpcl" aa'? 5 gg
$*333 Sow-?/5€wriK1, (Le¤_·L'i~,ue, {ea regu vb 0*-¢¤· r

Case 1 :08-cv—00143-SLR Document 1 Filed O3/11/2008 Page 2 of 2
AO 240 Reverse (Rev. IOIDJ]
DELAWARE (Rev SMG!
4. D0 you have any cash or checking or savings accounts? El Yes E’@
If "Yes" state the total amount $ l
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? aa»~A{ -
.1 ¤Yes -D/N€‘
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.
U M GM. I
. I declare under penalty of perjury that the above information is true and correct.
A irJ§[.iié0€ W
DA E 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. ,_____= M

Case 1:08-cv-00143-SLR

Document 1

Filed 03/11/2008

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Case 1:08-cv-00143-SLR

Document 1

Filed 03/11/2008

Page 2 of 2