I I AO 240 [Rev. IG/03]
DELAWARElRev. 4/G5!
P ` UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Q;. a gm 4. 5 Qnrnt
V. WITHOUT PREPAYMENT OF
Z: dc); ; 5;,;;; "`S`. ( in llglélé /6i*l to FEES AND AFFIDAVIT
Defendant(s) O _
` CASE NUMBER: on T T 5 8 W
I, gf Z. L) E" l,€_’__ , Y?) KO Q JC g ` declare that I am the (check appropriate box)
D Petition /Movant D Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am engitled tggthe relief
sought in the complaint/petition/motion, .
In support of this application, I answer the following questions under penalty of perjury; N
°â€â€˜
l. Are you currently incarcerated? I] Yes me (lf "No" go to Question ZE
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If "YES" state the place of your incarceration I ‘ ry
II :`*':gԤ
. Inmate Identification Number (Required): I"
. Areyou employed at the institution'? Do you receive any payment from the institution?
Attach a ledger sheet iam the institution of your incarceration showing at least the past six months ’
transactions `
2. Are you currently employed? El Yes §{hm
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 ,
~ _ - x { 5 . _ raw I
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3. In tl1e}ifizisi\I2 twelve months have ydu received any money Eomiany of theI'ollow1ng source . _ ·/
a. Business, profession or other self-employment D Yes [Q/N{
b. Rent payments, interest or dividends D Yes li/No
c. Pensions, annuities or life insurance payments D Yes DLNE
d. Disability or workers compensation payments @*5 El No
p e. Gifts or inheritances El Yes l?:L¢N’6
f. p Any other sources _ _ D Yes UGBQ
If the answer to any of the above is "YES" describe each source of money and state the amount I .
received AND what you expect you will continue to receive. px O
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Case 1 :07-cv—00758-SLR Document 1 Filed 11/26/2007 Page 2 of 2
AO 140 Reverse (Rev. IO/D3)
DELAWARE Rev. 4/05
4. D0 you have any cash or checking or savings accounts? Kifes K! No
If "Yes" state the total amount $ Q _
5 , Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property'?
El Yes Bw .
If "Yes" describe the property and state its value.
is 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. ‘
AJ a MJ -e
I declare under penalty of perjury that the above information is true and correct. r
[I [- .§?é~-c> 7 A L; gg; g_ A
· DATE SIGNATURE OF APPLICANT s
NOTE ro 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 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
I _ institutions, attach one certified statement of each account.
Case 1:07-cv-00758-SLR
Document 1
Filed 11/26/2007
Page 1 of 2
Case 1:07-cv-00758-SLR
Document 1
Filed 11/26/2007
Page 2 of 2
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