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

Case 1 :07-cv-00377-JJF Document 1 Filed 06/12/2007 P f 2
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UNITED STATES DISTRICT COURT 1 EOS? \
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
/ Z:/M FEES AND AFFIDAVIT
Defendant(s) — __ , __
` CASE NUMBER: G [ C3 fl 7
I, {,24: 2 [gg M H lg J declare that I am the (check appropriate box)
E 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 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 periury:
l. Are you currently incarcerated? Cl Yes me (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 iam the institution of your incarceration showing at least the gast six: months ’
transactions
2. Are you currently employed? H Yes E No
a. If the answer is "YES" state the amount of your take—hom:e salary or wages and pay period a
and give the name and address of your employer. g; ?'{d/£— fé
b. If the answer is "NO" state the date of your last employment, éigamount otjyzig gm-home I
salary or wages and pay period and the name and address of your last employer. U
3. In the past l2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment El Yes 4212., No
b. Rent payments, interest or dividends El Yes ‘iF—No
c. Pensions, annuities or life insurance payments D Yes E-No
d. Disability or workers compensation payments U Yes P1 No
e. Gifts or inheritances D Yes BL No
f. Any other sources E1 Yes ji-sNo
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-00377-JJF Document 1 Filed 06/12/2007 Page 2 of 2
AO 240 Reverse (Rev, 10/03)
DELAW'A.RE Rev. 4/052
4. Do you have any cash or checking or savings accounts? El Yes K 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?
El Yes yi 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. ‘
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I declare under penalty offperjury that the above information is true and correct.
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DATE ` Sl A I 1 "‘- PLI `· T r
NOTE TO PRISON]-ER: - 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.