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

Case 1 :07-cv—00084-SLR Document 1 Filed 02/15/2007 Page 1 of 2
:6 AO 240 [Rev. 10/CB)
DELAWARE Rev. 4[D52
,. . UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Piamiirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendant(s) -
/% CASE NUMBER:
I, /’ declare that l am the (check appropriate box)
°V‘ Petitioner/Plaintifwovant ° ° Other . -'-R i ‘‘‘D · . c-
in the above—entitled proceeding; that in support of my request to proceed without aym
28 USC §l9l5, l declare that l am unable to pay the costs of these proceedings an that ani;E@Jitlqd§o?§@.relie§
sought in the complaint/petition/motion. l ` `A e ti 5
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ln support of this application, l answer the following questions under penalty of peg i“t“ —· ·—=-- c._. _ __,i i
. ‘ 5 `“ " `“`‘ “ ‘is*:
l. Are you currently incarcerated? ° Kfes ° °No (lf "No" go to Question 2)BD G1 nn °l
, 7
_ lf"YES" state the place of your incarceration ;dé€{26é€i@&¢j M
Inmate Identification Number (Required): 5/bo I
Are you employed at the institution? M Do you receive any payment from the institution? M)
Attach a ledger sheet [rom the institution of your incarceration showing atleast the gast six months '
. transactions
2. Are you currently employed? ° ° Yes déo
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer. 2/ s
b. lf the answer is "NO" state the date of your last employment, the amount of your take-lymy
salary or ages and pa period nd the name and address of your last employer. jo? 7 2005
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3. ln the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · · Yes **4%
b. Rent payments, interest or dividends · · Yes J! No
c. Pensions, annuities or life insurance payments · · Yes ·‘/No
d. Disability or workers compensation payments · · Yes *·l·{ No
e. Gifts or inheritances · · Yes ·KNo
f. Any other sources · · Yes *4lo
lf 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—00084-SLR Document 1 Filed 02/15/2007 Page 2 of 2
AO 240 Reverse (Rev. 1.0/ D3) -
DELAWARE Rev, 4L'D5
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4. D0 you have any cash or checking or savings accounts? • • Yes @0
lf "Yes" state the total amount $ gf
5. Do y0u own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
· · Yes AQ
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 I
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.
gg/.¤°{¤?¢?` DATE SIGNATURE F 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.
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. A

Case 1:07-cv-OOOREAQRSLR Document 1-2 Filed O2/15/2007 Page 1 of 2
DELAWARE CORRECTIONAL CENTER
SUPPORT SER VICES OFFICE
MEMORANDUM 0 7 · 8 A
TO.- |1 t._,/Ah ) UA M SBI#.- Ltfltw
FROM; Stacy Shane, Support Services Secretary ‘ct·;- t·e- - ,.1 1 , _
RE.· 6Months Account Statement FEE $5 mw
DATE.- r 0 ,/L 1 . t
$[23 S carnrnt-4 www
Attached are co ies of your inma? account statement for the months of
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The following indicates the average daily balances.
MONTH AVERAGE 1>A1LYBA1;ANc12
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0 ter
Average daily balances/6 months: Q
Attachments
cc; File /,/3//d?, ,
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