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

Case 1 :07-cv—00230-JJF Document 6 Filed 06/13/2007 Page 1 of 3
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AO 240 (Rev. 10/03)
DELAWARE [Rev. 4;*05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
& Plaintiff APPLICATION TO PROCEED
.· V. r ` WITHOUT PREPAYMENT OF
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all/l"*?"'¥·€ @05245 jwyq FEES AND AFFIDAVIT
Defendant(s) , __ f"‘;—’__,
. _ CASE NUMBER: O :2- - 2, Zi) JJ
I, N]OYlCi I Q {Q declare that I am the (check appropriate box)
PGtiti0nG OVam I] Other Q. _.... -.. .._..... . . .... . .... ..
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in the above—entitled proceeding; that in support of my request to proceed without prepa 3 ent fees or costs under
28 USC §1915 I declare that I am unable to pay the costs of these proceedings and th t I a §» ent§t1Ll' HQ t t ` f
sought in th etition/motion. ` ` ?
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In support of this application, I answer the followi questions under penalty of perjury -- -sss '7r·g]ii i}i.!.gl{1§-li} il)i`?iMif;§E.. ,3
1. Are you currently incarcerated? EI No (If "No" goto Question 2)
It"'YES" state the place of your incarceration 6/ d(//? E2 COf@C7LgqD}¢Z/ /*/}
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Inmate Identiiication Number (Required): 5% L 2 E Z
Are you employed at the institution? Do you receive any payment from the institution?
Attach a led er sheet rom the in iitu ion 0 our incarceration showin at least the ast six nzont/1s' _
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2. Are you currently employed? El Yes No
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-a. If the answer is "YES" state the amount of your take-home sal q wages and pay period a l
and give the name and address of your employer, ig;
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 ame and address of your Est em. Ioyer. 0
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3. In the past 12 twelve months have you rec 1ved any money from any of the following sour es?
a. Business, profession or other self-employment EI Yes
b. Rent payments, interest or dividends _ E1 Yes we
c. Pensions, amiuities or life insurance payments El Yes JN0
d. Disability or workers compensation payments EI Yes JN0
e. Gifts or inheritances El Yes E//No
f. Any other sources El Yes 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. M G M

Case 1 :07-cv—00230-JJF Document 6 Filed 06/13/2007 Page 2 of 3
AO 240 Reverse [Rev. 10,/03)
DELAWARE skev. 4L'05l
4. D0 you have any cash or checking or savings accounts? El Yes la/(
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? [J
D Yes 0
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. 2 , ii .
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I declare under penalty of perjury that the above information is true and correct. J
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5/30 Nr » · {gm Q6 ~/
DATE i SIGNATURE 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 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.

Caselzgz-Ax/QQOQSO-JJF D0cument6_ Filed 06/13/2007 Page30f3
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