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

‘ . Case 1:07-cv-00164-SLR Document 1 Filed O3/22/2007 Page 1 of 2
_ . AO240(Rev,10/03) '
i DELAWARE gev. tig ‘ ‘ ‘ -
UNITED STATES DISTRICT COURT .
DISTRICT OF DELAWARE I
_ Plaintiff ‘ APPLICATION TO PROCEED
_ V. WITHOUT PREPAYMENT OF
Ed; `t;<—;\ O ,. 3,;* ·~~~ ;g·1—tL.t?s .~.T.»9:~.i..£.. FEES AND AFFIDAVIT
Defendant(s)
" CASENUMBER; O 7 · 1 6 ll, Q
I, l`<,Cl`J?`*`—, *—5` 1 ` \‘ r declare thatI am the (check appropriate box)
° ° Petitioner/l3_laintiff!Movant ° ° Ot.her E
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs ofthese proceedings and that I am entitled to the relief
sought in the clomplaint/petition/motion.
‘ In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ° .1,85- _ ° °No (If "No" go to Question 2) ·
_ uri! ’ ¤ I P, ; .
. If"YES" state the place of your incarceration ` - - { f Fli ‘ ' ` .
Inmate Identification Number (Requiredi: i " -` l l- A
Are you employed at the institution? hi O Do you receive any payment from the institution? rife) l
A Attach a led er sheet om the institution o our incarceration showin at le t »--._ ’
transactions - _
2. Are you currently employed? ° ° Yes No _} »- I we r *- 3 ` " - §
a. If the answer is "YES" state the amount of your take-home salary or ’ E
and give the name and address of your employer. LJIS.-l-llllc-l Q_F DEL'i'·l¥`?\l`·ll:
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. . In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment • • Yes No-
b. Rent payments, interest or dividends • • Yes ti • No _
c. Pensions, annuities or life insurance payments • • Yes · • No- _
d. Disability or workers compensation payments • • Yes -· an • No ~
e. Gifts or inheritances · • Yes {;_• • No
f. Any other sources • • Yes • • No i
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-00164-SLR Document 1 Filed O3/22/2007 Page 2 of 2
AO'1.40 Reverse (Rev. 10/03) ’
DELAWAFtEt§ev. MOE] U _
l 4. Do you have any cash or checking or savings accounts? • • Yes • • No i
If "Yes" state the total amount $ · V
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other .
_ valuable property? ‘ .
* ··Y¤—<» -.,._ _··N¤ r
If "Yes" describe the property and state its value. ` ‘ an
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.
_ I declare under penalty of perjury that the above information is true and correct.
DATE. "- 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.

Qase 1:07-cv-00164-SLR Document 1-2 Filed O3/22/2007 Page 1 of 2
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