Case 1 :06-cv-00007-JJF Document 1 Filed 01/04/2006 Page 1 of 2
AO 240 (Rev. 10/03)
DELAWARE {Rev. 4105)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
i;D-HEQS. l
Plaintil APPLICATION TO PROCEED
\ ‘ _ — .._V. p [ WITHOUT PREPAYMENT OF
Qt sl>tQJr»Q lEgiJ:2id I sl QQ2 l FEES AND AFFIDAVIT
De endant(s) 6 __ T
. _ CASE NUMBER: O
I, gdi illllrh i ll Meg i K A -declare that I am the (check appropriate box)
° ° Petitioner ff, ovant ° ° Other
I V`"""†`P‘†. rr . ·· ·
in the above-entitled proceeding; that in support of my request to proceed without prepaymexlt of fees oricostsunder _!
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I gm enhtled tothe rerrerrt “"‘ `
sought in the complaint/petition/motion. i _
4 it ¥’ · » » · A
f \..’ .` t " _ _ _
In support of this application, I answer the following questions under penalty of perjury: ~— _·—-— $-1; {AAAI; A. to A A_ i ~
l l. Are you currently incarcerated? ° °No (If "No" go to QuegliOn.2)..l[i‘; ’-it A '_ _ H
If "YES" state the place of your incarceration ~— bib ZX K T` l ij AJ lll- .. Juli ·
- Inmate Identification Number (Required): rig Q jg (jg gg [
Are you employed at the institution? Mo Do you receive any payment from the institution? UC}
Attach a ledger sheet from the institution of your incarceration showing at least the gast six months’
transactions
2. Are you currently employed? ° ° Yes
_ 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.
3. In the past I2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment • • Yes · • {
b. Rent payments, interest or dividends • • Yes · Aj`
c. Pensions, annuities or life insurance payments · · Yes · _ _.‘
d. Disability or workers compensation payments · • Yes •
e. Gifts or inheritances • · Yes J N )
f. Any other sources • • Yes · 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-00007-JJF Document 1 Filed O1/O4/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/ 03) `
DELAWARE [Rev. 4£05l
4. Do you have any cash or checking or savings accounts? • • Yes
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? -——j\_
• • Yes @0 _l-
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.
I declare under penalty of perjury that the above infomation is true and correct.
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DATE SIGNATURE OF AP LICANT
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 appropriateinstitutional
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.