AO 240 (Rev. I0/03)
DELAWA.RElIkev. 4./05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
3 Z alli A gpgrig mil
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
I`?) Bu Ft { [QQ sl l·< og AME QI CQ FEES AND AFFIDAVIT
efendant(s)
I CASE NUMBER: ?" _ 3 G
I, i` Q Q QA gl gl E2 declare that I am the (check appropriate box)
lj 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 §l9l5, I declare thatl 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 lg/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 /ea'g_ er sheet Qorn the institution of your incarceration showing ar least the gas! six mont/1s’
lransactions
2. Are you currently employed? El Yes E/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 address of your last employer. Si? [l g ROR
3. In the past l2 twelve months have you received any money from any ofthe following sources? A
a. Business, profession or other self-employment El Yes zi No
b. Rent payments, interest or dividends 1:1 Yes si No
c. Pensions, annuities or life insurance payments Q, Yes El No {(,5 7 S m nba
d. Disability or workers compensation payments sf Yes El No {qa;} DO m U IG
e. Gifts or inheritances El Yes H1] No I mtfalaé
f. Any other sources El Yes B, 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 :07-cv—00390-SLR Document 1 Filed 06/19/2007 Page 2 of 3
AO 240 Reverse (Rev. ll]/U3]
DELAWARE !Rev. 4/05)
4. D0 you have any cash or checking or savings accounts? Ki/Yes El No
l
If`lY€SrI state 3,1`["lOL1l'lt $ 4*
l
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5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other `
valuable property?
E3/Yes E! No .
IE'Y€S" @(3,;-ibe the property and state l'tS V&lU€¤.
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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.
hr i 2, ag ~ mu,
DATE NATU OF APPLICANT ·
NOTE T0 PRISONER: i 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.
00 Case1:07—cv-00390-SLR D0cument1 Filed 06/19/2007 Page30f3
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