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

Case 1 :07-cv-0021 3-IVI PT Document 1 Filed O4/20/2007 Page 1 of 2
AO 240 (Rev. 10/ D3)
DELAWAREjRev. AIDS;
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
V. _ WITHOUT PREPAYMENT OF
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De endant(s)
CASE NUMBER: Q T ·‘ 2 'I 3 —··
I, l L . A [ l (Ll] Qi" declare that I am the (check appropriate box)
° ° Petitioner.’Plaintiff/Movant ° ° Other
in the above~e11titled proceeding; that in support of 1ny request to proceed without prepayment of fees or costs under
28 USC §1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitionfmotion.
In support of this application, I answer the following questions un der penalty of perjury:
_ I. Are you currently incarcerated? ° °1'es ° °I\ir( (If "No" go to Question 2)
lf "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 goin the institution ofyourig1carcerat1‘on showing at least the gust six nzontl1s’
transactions
2. Are you currently employed? ° ° Yes ° M
— a. If the answer is "YES" state the amotmt of your take-home salary or wages and pay period a
and give the name and address of your employer.
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. Inthe past 12 twelve months have you received any money from any of the following sources?
./'
a. Busmess, profession or other self—employment • • Yes ` •' • No -
b. Rent pay1nents,interest or dividends • • Yes ·/‘ • • No
c. Pensions, annuities or life insurance payments • • Yesl/V • • No
d. Disability or workers compensation payments • • Yes • · No./
e. Gifts or inheritances · • Yes • · No»/
f. Any other sources • • Yes • • No 4/
If the answer to any of the above is "YES" describe each source of 111oney and state the amount
received AND what you expect you will continue to receive. _ y
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Case 1 :07-cv-0021 3-IVI PT Document 1 Filed O4/20/2007 Page 2 ot 2
AO 240 Reverse (Rev. 10/ D3)
DELAWARE lRev. ¢1£[l5l
4. Do you have any cash or checking or savings accounts'? • • Y es • • No ·
If "Yes" state the total amount $ 69 Z Zi @5/ ,
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? P,
• • Yes • •No
If "Yes" describe the property and state its value. _
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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 of periury that the above infonnation is true and correct.
DAT — SIGNATURE OF APPLICANT ,cU·’/
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. `