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

_ ‘ Case 1:07-cv-00365—JJF_ Document 1 Filed 06/08/2007 Page 1 of 2
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UNITED STATES DISTRICT COURT
Q DISTRICT OF DELAWARE
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_ lamitrf APPLICATION TO PROCEED
_ V. WITHOUT PREPAYINIENT OF
FEES AND AFFIDAVIT
Defendantls) .
·i casa NUMBER: --r 0 7 ” 3 6 5 '*"
I, izjhgj {lg;} (gg K )& declare that I am the (check appropriate box) -
° ° Petitioner/Plaintifnfh/iovant ° ° Other I I im `A'``'DD l
l in the above-entitled proceeding, that in support of my request to proceed without pre of fees or costs
28 USC §l9 15, Ideclare that I am unable to pay the costs ofthese proceedings and at l m¤diiiiii:iled sought in the complaint/petition/motion.
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‘ In support of diis application, I answer the following questions under penalty of perjury: if ``'` D ``=` ‘0’‘ " ‘`a·‘·
l. Are you currently incarcerated? ° °No (If "No" go to Question 2)
. If"YES" state the place ofyour incarceration Jgit ll, ., l30l 5i`- wifm- iqiwci
Inmate Identilicatiori Number (Required): rl jhiil] ia ,
Are you employed at the institution? QL Do you receive any payment from the institution? A
ledger sheer fronlrfie fristiftznon oft·o:.i.r fncorceraion risowirier of least the geist six TT70flf.:l.$"
transactions p t
2. Are you currently employed? ° ° Yes ® -- l -
a. If the answer is "YES" state the amount of your talte·home salary or wages and pay period a
and give the name and address of your employer.
b. Ifthe answer is "NO" state the date of your last employment, the amount of your take-home
{ sala or wages and pa period and the name and address of your last employer.
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3. . In the past 12 twelve months have you received any money from any of the following so ces?
a. Business, profession or other self—employrnent • • Yes `
b. Rent payments, interest or dividends l ‘ • · Yes · •
0. Pensions, annuities or life insurance payments • • Yes
d. Disability or workers compensation payments • • Yes · • I i
e. Gifts or iriheiitances • • Yes
f. Any other sources · • Yes • No _ `
If the answer to any of the above is "Y`ES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

, _ Case 1 :07-cv-00365-JJF Document 1 Filed 06/08/2007 Page 2 of 2 .
. AO 240 Reverse [Rev. ltJi’D3] ,
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O 4. Do you have any cash or checking or savings accounts? • ' Yes
Ii°"Yes" state the total amount S ‘
15. Do you own any real estate, stocks, bonds, securities, other tinancial instrurnents, automobiles or other
_ valuable property? ‘
• · Yes ®
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 O
indicate how much you contribute to their support, OR state NONE if applicable.
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_ I declare under penalty ofpeijury that the above information is true and correct.
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DATE. i SI ATURE OF APPLICANT .
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 certitied by the appropriate institutional
ofticer showing all receipts, expenditures, an d balances during the lastsix months in your institutional accounts.
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.