I AO 240 (Rev. 10/O3)
DELAW/\RElRev. 4/05
I UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
. _ t r’tr,· t
_ . _, V. ,¤ ·‘ _ , WITHOUT PREPAYMENT OF
"*—zf·>` — . » ccf La,/»,,.»~‘ FEES AND AFFIDAVIT
Defendan (s) W
CASE NUMBER: Q 6 ·— Y ;: I;
I,) _ »{;’é/=72·z_ declare that I ain the (check appropriate box)
Q Petitioner/Plaintiff/Movant El Other
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 complaint/petition/motion.
In support of this application, I answer the following questions under penalty of periury:
I. Are you currently incarcerated? El Yes H No (lf "No" go to Question 2)
If "YES" state the place of your incarceration __,_ _ ` _ _
Inmate Identiiication Number (Required): _ _ _ __ g
Are you employed at the institution? Do you receive any payment from the institution? _
Attach a ledger sheet @*0111 the institution of your incarceration showing at least the gas! six months '
transactions _ _' { if /
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2. Are you currently empijidyed? IE Yes E No jg, , __, _,_-é jri ,;__. tl., A Je "
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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.
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. /‘/t.‘ i' Wir- {Li} I: Y __ I,
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3. In the past 12 twelve months have you received any money from any ofthe éllowing sources? {be-; t` <*` ¤’· 1 »t!J»u
a. Business, profession or other self—employment E1 Yes ZT; No
b. Rent payments, interest or dividends D Yes )Z’ No
c. Pensions, annuities or life insurance payments E1 Yes Qt No
d. Disability or workers compensation payments ,5, ,»",;i[; I? Yes El No
e. Gifts or inheritances " E1 Yes ,J2" No
f. Any other sources El Yes iii No
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. It l, 6 gr; rtl t’»i··/·/1 ge; c Ml
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Case 1:06-cv-00766-SLR Document 1 Filed 12/14/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARE Rev. 4/05)
4. D0 you have any cash or checking or savings accounts? K(Yes E1 No
If "Yes" state the total amount fl? éigjj QL
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _
E1 Yes Q"’No
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each persgi
indicate how much you contribute to their support, OR state NONE if applicable. 3 {ij;
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I declare under penalty of perjury that the above information is true and correct.
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ATE » L SIGNATURE OF APPLICANT
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NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an
afiidavit 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.
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