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

Case 1 :06-cv-00068-JJF Document 1 Filed 02/01 /2006 Page 1 of 2
AO 240 (Rev l0/03)
DELAWARE. Rev. 4/05 __
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UNITED STATES DISTRICT COURT ‘
DISTRICT OF DELAWARE FEB - 1 mg _
L U.S. DISTRICT Ciigxlligig
Plaintif ’ APPLICATIO N I z- *2 i. ’ ‘=
V. _ WITHOUT PREPAYMENT OF
gigjpn/»<'&» £r%;`/Qaccl g @4/ FEES AND AFFIDAVIT
Defendant(s)
p p CASE NUMBER: O 6 _ 6 8
L /(/Jl MC Ig declare that I am the (check appropriate box)
w Petitioner/Plaintiff/Movant E1 Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the comp]aint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ij Yes m No (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution'? Do you receive any payment from the institution'?
Attach a ledger sheet Qorn the institution of your incarceration showing at least the gast six: n2onths'
transactions
` 2. Are you currently employed? E Yes III No
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. ?> Og
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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 fro1n any of the following sources?
a. - Business, profession or other self-employment III Yes DY No
b. Rent payments, interest or dividends III Yes II2I/ No
c. Pensions, annuities or life insurance payments III Yes {No
d. Disability or workers compensation payments III Yes W/No
e. Gifts or inheritances EI Yes IB/ No
f. Any other sources EI Yes EY 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.

Case 1 :06-cv-00068-JJF Document 1 Filed O2/O1/2006 Page 2 of 2
AO 240 Reverse (`Rev_ IOIOJ)
V DELAWARE Rev. QIOS! `
4. Do you have any cash or checking or savings accounts? {Yes E1 No
If "Yes" state the total amount $ /§0 » O G C02:}.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? `
. E1 Yes !E:"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 person and
indicate how much you contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above infomation is true and correct.
,9 [L [C, & Q£.»{:a.. x/A-
ATE SIGNATURE $1* 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.