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UNITED STATES DISTRICT COURT 7 pp A l
QC; M0 i g 6/ &;3ISTR.lCT OF DELAWARE QQ
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1-gfaintiff C? APPLICATION TO PROCEED M
WITHOUT PREPAYMENT OP y
v. rates ann arrinavir ck, l
Doug /625 do I ——- l
D endant(s) CASE NUMBER: d_ se _
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L 5 ‘ I declare that I am the (check appropriate box)
Petitione < *-Movant l] Other in the above—entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under·?,S USC p§l915,p I declare that I am » T
unable • ay the costs of these proceedings and thati am entitled to the relief sought in the l · l
etition/motion. p . ' -
Ln support of this application, I answer t ·questions under penalty of perjury: `
PV jr"-V'; - ` `A*»""ii- `- — .° " " ' ., , ` V t . `- i
1. Are you currentlyiincarceraied? n ` esi] No" (If "`No*' go to Question 2) _ " " A · · r
If "YES" state the place of your incarceration 5 C;
Are you employed at the institution? E Yes (Et/Fit?/I ` ' "O D `
Do you receive anypayment from the institution? El Yes Mil i
. - . _ . l
‘ Have the institution [zi! out the cemdcaze oortion of`thi.s affialavit analattach a lea'? er sheet frown the l
institution/sl of vom- incarceration slzowinv, at least the past SIX rn0nths' ti·ansactz`ons. Leda, er
._ sheets are not reaziireal for cases filed ursziant t .28.·t’,=ZS`C §2254. l · " iei" {
2. Are you currently employed? Cl Yeas Q No ` i
a. if the answer is "YES" state the amount of your tal
pb. 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. M
3. in the past l2 twelve months have you received any money from any ofthe following sources? _
a. Business, profession or other seliiemployrnent C] Yes O l
b. Rent payments, interest or dividends K] Yes Ep; l
c. Pensions, annuities or life insurance payments El Yes E}>· I
- d. Disability or workers compensation payments . Cl Yes E])¢o/ ap i
e. Gifts or inheritances Cl Yes Gy
- f. Any other sources Cl Yes No
If the answer to any ofthe above is "YES" describe each source ofmoney and s te the amount A
L received AND what you expect you will continue to receive. fj
_ Case 1 :08-cv—OOO72-JJF Document 1 Filed O2/O4/2008 Page 2 of 3
- 4. Do you have amp each or checking? or savings accounts? Cl Yes {2% ‘ ·
lf "Yes" stare the total arnount S T l
5_ - Do you nwnrany realestate, stocks, bonds, securities, other tinancial in 'automobileg O; 1 l
other valuable property? E] Yes 1EO J
If "Yes" describe the property and state its value. l
l
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how rnucb you contribute to theirsupport, QR S te .VO.·V£ if applicable. E
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I declare under penalty of perjury that the above infomation is true and correct. _ _
Date: [ .. p _ Signature ot`App1icant -
Case 1 :08-cv—OOO72-JJF Document 1 Filed O2/O4/2008 Page 3 of 3
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Case 1:08-cv-00072-JJF
Document 1
Filed 02/04/2008
Page 1 of 3
Case 1:08-cv-00072-JJF
Document 1
Filed 02/04/2008
Page 2 of 3
Case 1:08-cv-00072-JJF
Document 1
Filed 02/04/2008
Page 3 of 3
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