Free Order - District Court of Delaware - Delaware

Case 1:08-cv-00070-SLR Document 3 Filed 02/20/2008 Page 1 of 1
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
SYED M. HUSAIN, MD, PhD, )
I
Plaintiff, )
I
v. ) Civ. No. 08-70-SLR
I
GUY PERROTTI, ACTING )
DIRECTOR, DELAWARE )
PSYCHIATRIC CENTER, )
I
Defendant. )
O R D E R
The plaintiff, Syed M. Husain, has filed this action without prepayment of
the filing fee or a request to proceed in forma pauperis.
At Wilmington thisdwday of February, 2008, IT IS ORDERED that:
The plaintiff shall, within tvventy—one days from the date of this order,
either: (1) submit an application to proceed without prepayment of fees, or (2) pay in full
the $350.00 filing fee.
Failure to timely comply with this order shall result in dismissal of
this case without prejudice.
United States Dgtrict Judge

Case 1 :08-cv—OOO70-SLR Document 3-2 Filed O2/20/2008 Page 1 of 2
AO 240 (Rev. 10/03)
DELAWARE Rev. 5{06
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: 08-70-SLR
I, declare that I am the (check appropriate box)
El Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §19l5, 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? El Yes El No (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 sheet [rom the institution ot your incarceration detailing all transactions over the gast
sit months.
2. Are you currently employed? El Yes El No
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 ofyour 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 Iast employer.
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment III Yes El No
b. Rent payments, interest or dividends D Yes D No
c. Pensions, annuities or life insurance payments E1 Yes El No
d. Disability or workers compensation payments D Yes D No
e. Gifts or inheritances El Yes E1 No
f. Any other sources D Yes D 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.

Case 1:08-cv—O0O70-SLR Document 3-2 Filed O2/20/2008 Page 2 of 2
AO 240 Reverse (Rev. IO/03)
DELAWARE tRev 5{06
4. Do you have any cash or checking or savings accounts? Cl Yes Cl No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
E1 Yes D No
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.
I declare under penalty of perjury that the above information is true and correct.
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-00070-SLR

Document 3

Filed 02/20/2008

Page 1 of 1

Case 1:08-cv-00070-SLR

Document 3-2

Filed 02/20/2008

Page 1 of 2

Case 1:08-cv-00070-SLR

Document 3-2

Filed 02/20/2008

Page 2 of 2