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

Case 1:07-cv-00005-SLR Document 1 Filed O1/O4/2007 Page 1 of 2
ԤrAO 240 (Rev. 10/03)
UNITED STATES DISTRICT COURT
District of
APPLICATION TO PROCEED
Plaintiff WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
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CASE NUMBER: O T "` G 5 - `T I!
Defendant A -
E . . ZE] we . .“
[_ J! , . '-·/ .3** . `{/it ,; A T '{ declare that I am the (check appropriategbox) l
I]petitioner/plaintiff/movant I] other 'Y l g
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §19l5 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? I] Yes lEl’Nfo (If "No," go to Part 2)
If “Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? I] Yes Eldffo
a. If the answer is "Yes, " state the amount of your take-home salary or wages and pay period 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.
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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 I] Yes [I N o
b. Rent payments, interest or dividends El Yes I] No
c. Pensions, annuities or life insurance payments El Yes I] No
d. Disability or workers compensation payments |Zl’Yes I] No
e. Gifts or inheritances I] Yes I] No
f. Any other sources I] Yes I] No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.

Case 1:07-cv-00005-SLR Document 1 Filed O1/O4/2007 Page 2 of 2
AO 240 Reverse (Rev. 10/03)

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4. D0 you have any cash or checking or savings accounts? [I Yes lEl’No
If “Yes," state the total amount.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? |El’Yes I] No
If “Yes," describe the property and state its value. _
ria-·t 3-at .l sk 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.L_ - , V _r I _ T _'
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IZ`;>A\ [iff: _ KJ L l ,( J ~_r' I /
I declare under penalty of perjury that the above information is true and correct.
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ate i _ ` `aturg9ofApplicam
NOTICE 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.