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

Case 1 :07-cv-00376-JJF Document 1 Filed 06/12/2007 Page 1 of 2
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" UNITED STATES DISTRICT CO ' T IW 1 (
DISTRICT OF DELAWARE ‘” "’ l 2 AUG?
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`_ ' if ll p DISEIHGI GF
riaraarr ‘ I APPLICATION T
V. WITHOUT PREPAYMENT OF
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M ,g;;t;)¢2g""[gg) [ FEES AND AF FIDAVIT
Defendant(s)
I CASE NUMBER: 0 7 " 3 T 6
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I, /Z fg Q gf E Z I declare thatl am the (check appropriate box)
K 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/petitionfmotion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? lj 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 [rom the institution of your incarceration showing at least the past six months ’
transactions " -
2. Are you currently employed? Yes El No,
a. If the answer is "YES" state the amount of your tal;e}1ome_ salary or wa es and pay p iod a
and give the name and address of your employer 'Nf/¥"‘f } J
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b. If the answer is "NO" state the date of your last emgldlygrigfi é amount oggir éike-ho e
salary or wages and pay period and the name and address of your last 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 El Yes jg No
b. Rent payments, interest or dividends El Yes No
c. Pensions, annuities or life insurance payments El Yes No
d. Disability or workers compensation payments El Yes 5¢`No
e. Gifts or inheritances El Yes §QNo
f. Any other sources III Yes Q,E.l§Io
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-00376-JJF Document 1 Filed 06/12/2007 Page 2 of 2
AO 240 Reverse (Rev, IUIUB)
DELAWAIlE$Rev. 4/D5!
4. Do you have any cash or checking or savings accounts? E1 Yes we
lf "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
¤ Yes %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. s ,
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· I declare under penalty of perjury that the above information is true and correct.
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i DA% ;’ SI · · PLICANT
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.