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

Case 1 :08-cv-00124-JJF Document 1 Filed O3/O3/2008 Page 1 of 2
I AO 240 (Rev. IDIDS)
DELAWARE Rev. AIDS}
` UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
me- Jiri:
Ig;} QICJPWV
I ·- ,,• .__ i I In CIC of-
A JS S Avy ‘·‘°
Plaintiff A APPLICATION TO PRQA;§EE€g§*¤
V. WITHOUT PREPAYMEQIT , f`
Ceo o 7 l l 25 g lgzigf Fans AND AFFIDA§IT
Defendant(s) O to
` CASE NUMBER: 8 ` I 2 A
,___ _ /` •·
I, [—- [ & Cj L /2/[ ,5 { jh , gl AJ Ydeclare that I am the (check appropriate box)
E PetitionerfPlaintifffl\/Iovant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitionfmotion. .
In support of this application, I answer the following questions under penalty of perjury;
l. Are you currently incarcerated? Cl Yes E No (If "No" go to Question 2)
If "YES" state the place of your incarceration . `
. Inmate Identification Number (Required);
Areyou employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet ion; the institution of your incarceration showing at least the past six months
transactions
2. Are you currently employed? El Yes % No
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 addre s of your last employer.
for ,,2ag7 Det gmk f/°?·2-{¢-e—··Q;/
3. In the past I2 twelve mont s have you received any money from any of the following so ces? .
a. Business, profession or other self—employment f Yes lj No
b. Rent payments, interest or dividends El Yes Ec No
c. Pensions, armuities or life insurance payments E1 Yes XEQ No
d. Disability or workers compensation payments EQ Yes III No
p e. Gifts or inheritances El Yes /l§ No
f. Any other sources E1 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. (TSW 7’ //6) e
#"’“`” I I 5 •

Case 1 :08-cv-00124-JJF Document 1 Filed O3/O3/2008 Page 2 of 2
AO 240 Reverse [Rev. IDIDB} A
DELAWARE$Rev. =1:'D5
4. Do you have any cash or checking or savings accounts? A Yes El No
lf "Yes" state the total amount $ O 2 O
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _
GQ Hq; )Q Yes E1 No
If"Yes" describe the property and state its value.HOLdS A").
A )
L
6. List the persons who are dependent on you for support, state o elationship to each person and
indicate how rnuch you contribute to their support, OR sta NONE applicable. ·
l declare under penalty of perjury that the above information is true and correct.
· i / ,/·/ ‘ ,/
~. Jig ___ 1,;.2. . .. 4../ "‘ Zfér
DATE SIGNATURE OF APPLICANT b
NOTE TO PRISONER: - A Prisoner seeking to proceed without prepayment of fees shall submit an
afiidavit stating all assets. Inaddition, a prisoner must attach a statement certified by the appropriate
institutional ofiicer 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 certitied statement of each account.

Case 1:08-cv-00124-JJF

Document 1

Filed 03/03/2008

Page 1 of 2

Case 1:08-cv-00124-JJF

Document 1

Filed 03/03/2008

Page 2 of 2