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

Case 1 :07-cv-00230-JJF Document 23 Filed 12/27/2007 P
I I AO 240 [Rev. l0/D3) F I L E m
DELAWARE Rev. 4/05
. ` 2 2007
‘ UNITED STATES DISTRICT COURT DEC 7
DISTRICT OF DELAWARE UAS. Umm COURT
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riaisarr APPLICATION TO PROCEED
(J O.,M··5,Tla0m¤t5 ca,-mXNq.+q Sm L, ,yOm SW,,,—}},) WITHOUT PREPAYMENT OF
_<}¤·ti·<3¤~tte..\.g{ slmgij no its mgm? nggg Uéhg gm, FEES AND AFFIDAVIT
w-L {mms Defendant(s) c 3
= isldenqu ‘ casenuivtess; CA sv- a30 JTl -
I, Eg pm QD QQ E, · (O he declare that I am the (check appropriate box)
M Petitioner/Plaintiff/Movant El Other
- in the above-entitled preceeding; 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 th motion.
In support of this application, I answer the following questi penalty of perjury:
l. Are you currently incarcerated? El Yes No (If "No" go to Question 2)
If "YES" state the place of your incarceration . -`
Inmate Identification Number (Required):
A . . . , Mit . . . . it /4
y _ re you employed at the institution. { Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution of your incarceration showing atleast the past six months ’
- transactions l ` · `
` 2. Are you currently employed? T No U _
a. If the answer is "YES" state the amount of your take-home salary or wages anu pay period a
and give the name and address of your employer. M
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. (3 J 3-.»
3. In the past l2 twelve months have you received any money from any of the following sources? I
¥ a. Business, profession or other self-employment El Yes élo
_ b. Rent payments, interest or dividends D Yes No
c. Pensions, annuities or life insurance payments E1 Yes ?i<6
d. Disability or workers compensation payments El Yes B/No
p e. Gifts or inheritances Ct Yes o
f. Any other sources p 1:1 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.

Case 1 :07-cv-00230-JJF Document 23 Filed 12/27/2007 Page 2 of 2 y
. AO 240 Reverse (Rev. 10/03)V
I DELAWARE£Rev. 4/D5! V
4. Do you have any cash or checking or savings accounts? El Yes El’Nb'/’ °
If "Yes" state the total amount SS · L
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or pthers ,
valuable property? »r”” 'iil
u Yes _ Z
lf "Yes" describe the property and state its value. »
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I- 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. A
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I declare under penalty of perjury that the above information is true and correct.
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- DATE SIGNATURE OF APPLICANT ·
NOTE ro 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. .