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

Case 1 :08-cv-00142-JJF Document 1 Filed O3/10/2008 Page 1 of 2
AO 240 {Rev. 10/0])
DELAWA.R.EtRev, 51'U6
DISTRICT OF DELAWARE i M if ` as H I-
il lii¤ 37
l?Q.£ li ng valglgs T, tlc
e+c»l-. Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
{James R. Jbhnspn FEES AND AFFIDAVIT
Defendant(s) ' _ _1 7_ 1
CASE NUMBER: O 8 1 A 2 A
I, T C5 R jg QYLCOK] declare that I am the (check appropriate box)
El PetitionerfPlaintiff/Movant E Other
in the above—entitled proceeding; that support of my reques-t~ to proceed without prepayment of fees or co sts under A
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that Iam entitled to-the relief i `
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury: I
1. Are you currently incarcerated? l El Yes No (lf 'lNo" go to Question 2) _
If "YES" state the place of your incarceration A -
Inmate Ideutiiicatiou Number [Required): i _ l
Are you employed at the institution? I Do you receive any payment from the institution?
Attach a ledger-sheet from the institution og your incarceration detailing all transactions over the gas:
sb: months. A -
2. Are you currently employed? -‘- D Yes No l `l` " A"'
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 aqgfgyl peréqrgzgig the name argc; Laldddaesg 2£tg}L;`J1],I.I' laEt_ 'eénployer.
3. A In the past 12 twelve months have you received any money irom einy ofihgfiilowing sources?
a. Business, profession or other se1f—emp1oyment E1 Yes U No
b. Rent payments, interest or dividends its Yes D! No
c. Pensions, annuities or life insurance payments El Yes M No
d. Disability or workers compensation payments EJ Yes Bl No
e. Gifts or inheritances EI Yes m No
f. Any other sources EI Yes M 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.
qt 50. 00 love. effertrwj from ¢»l¢»u.n;}A,

Case 1 :08-cv-00142-JJF Document 1 Filed O3/10/2008 Page 2 of 2
AO 24U Reverse {Rev. IDIOJ)
DELAWARE llsav SIUE!
4. D0 y0u have any cash or checking or savings accounts? N Yes E1 No
union ·
If "Yes" state the total amount $ Z?. QO
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ,_>,§j¥g~t ,£"¢n J°·§*»‘7;
ii - , !. ~ufJ . Yes ElNo
If "Yes" describe the pro · i and stat its value. {
me %‘ W I
6. List the persons vvh_o are dependent on you for support, state your relationship to each person and I
indicate how much you contribute to their support, OR state NONE if applicable.
jbfdyy fi. I declare under penalty of perj my that the above information is true and correct.
03*/O‘D& I _ mil"! [1,- . ~’
DATE I SIGNATURE O In PLICANT
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. _ __ p

Case 1:08-cv-00142-JJF

Document 1

Filed 03/10/2008

Page 1 of 2

Case 1:08-cv-00142-JJF

Document 1

Filed 03/10/2008

Page 2 of 2