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

Case 1 :06-cv-00042-KAJ Document 1-3 Filed 01/23/2006 Page 1 of 3
' AO 2-1D(Rr‘£v. I0/O3)
‘ `DELAWARE(Rev_ 4/esi i § 9
UNITED STATES DISTRICT COURT
_ DISTRICT OF DELAWARE ‘
at at t
c> W . no O/7
Piainnrr APPLICATION TO PROCEED
AQ! J V. . .· I WITHOUT PREPAYMENT OF
Q7 ,—V id/tqé /VK?/~>" FEES AND AFFIDAVIT
Defendant(s) 5 3
J . CASE NUMBER: U iii ` A 2 IIIAI
I, A , 4( ‘ { ` declare that I am the (check appropriate box)
M. 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 §l9l5, I declare that I am unable to pay the costs of these proceedings and that l am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, l answer the following questions under penalty of perjury:
l. Are you currently incarcerated? El Yes B. No (lf "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? g Do you receive any payment from the institution'?
Attach a lcdg or sheet Qoni the institution of your incarceration showing atleast the ,g;astsLv1nonfJ1s’
transactions
2. Are you currently employed? El Yes E 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.
h. 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.
°. ith t12twl thh `dy f fthfll ` ?; I
a n e pas e ve mon s ave you receive any money rom any o e o owing sources S/dé ' A
a. Business, profession or other self-employment Yes El No A
b. Rent payments, interest or dividends U Yes `§\N0 (30
c. Pensions, annuities or life insurance payments D Yes No CW I { _
d. Disability or workers compensation payments El Yes No _ 5 Qt
e. Gifts or mhenemees ¤ Yes ‘ No /Wrr/rr% page ·
f. Any other sources g El Yes `A No 66/ 67
If the answer to any ofthe above is "YES" describe each source of money and state the amount fr -·•
received AND what you expect you will continue to receive. mgm A gg
1'Dx .» i/nerr

Case 1:06-cv-00042-KAJ Document 1-3 Filed 01/23/2006 Page 2 of 3
AO 240 Reverse (Rev. 10/O3)
DELAWARE [Rev. MOS!
4. Do you have any cash or checking or savings accounts? ‘ El Yes No I
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
g El Yes F. No
If "Yes" describe the property and state its valne.
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. /U0mé;
I declare under penalty of perjury that the above information is true and correct. `
3 glut! J , 4 A 4,
ATE i ` SIGNATURE OF APPLICAN
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. ·

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