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

· a Case 1 :07-cv-00070-SLR Document 17 Filed 10/O2/2007 Page 1 of 3
D 1; QL ie I Ir ie I
AO 240 (Rev. IO/03]
DELAWARE ev. 4 U5 E
_ OCT — 2 EOGY * l
UNITED STATES DISTRICT COURT I E gy _} I
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DISTRICT OF DELAWARE us. nisraict count I
_ DISTRICT OF DELAIMIRE Z i
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. Piamirt APPLICATION TO PROCEED
G av. 5, WITHOUT PREPAYMENT OF
O r’/6»c>£'&>/7%/ é 0{/c£/ FEES AND AFFIDAVIT “
Defendant(s) i
cAsn NIJMBER: 0 7 *0 7d - SLK
I, fc l I S2 A'! S0/I declare that I am the (check appropriate box)
E/ Petitioner/Plaintiff/l\/Iovant El Other a i
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitiori/motion.
In support of this application, I answer the following questions un er penalty of perjury: . _
1- Are you ._ _r`r_ YBS1 I in nl I E N0 Qugstignl I l
If "‘YES" state the place ofsyour incarceration _ _ _
Inmate Identification Number (Required): ` U l
Are you employed at the institution? iDo you receive any payment from the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the past six months ’
transactions ` .
2. Are you currently employed? El Yes o
l
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a I
and give the name and address of your employer. l
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. I
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business,. profession or other self-employment _ El Yes U _p/0
b. 1 Rent payments, interest or dividends - - A -- El Yes . .. r . __ I _
c. Pensions, annuities or life insurance payments El Yes /I2)k)
2 cl. .2 F Disability__or;worl _ e. Gifts or inheritances U ` · ‘¤ `Yes ` “ ” · o · l
f. · I ` Any other sources - t _ _ I _|Z| Yes _ _ No l
If the answer to any of the above is "YES" describe each source of money and state the amount i
received AND what you expect you will continue to receive. a
i

‘ Case 1 :07-cv-OOO70—SLFi Document 17 Filed 10/O2/2007 Page 2 of 3
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AO 240 Reverse (Rev. 10/D3)
DELAWARE !Rev. ·i£(l52
4. D0 you have any cash or checking or sgtings accounts? JA es E1 N0
If "Yes" state the total amount $ _ 6 O_ _ _
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ` ·-_'
_ U U Yes No
If "Yes" describe the property and state its value. l
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
I declare under penalty of perjury that the above information is true and correct.
•- ( i
DATE ;SIGNA GRE OF §PPLICANT
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 l
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.

Case1:O7-cv-OOp7Q; L — =_7 10/O”§2007 Page$0f3
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