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

A Case 1 :06-cv—00009-GIVIS Document 1 Filed 01/05/2006 Page 1 of 2 .
AO 240 (Rev. 10/03)

UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Piaimirr APPLICATION TO PROCEED
. V. WITHOUT PREPAYMENT OF
D at /l”l ac pee Q FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: r`.‘ i` Q
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I, declare that I am the (check appropriate box)
{`Petitioner/Plaintift7Movar1t El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of tees 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 complaint/petition/motion.
In support of this application, I answer the following questi penalty of perjury:
l. Are you currently incarcerated? El Yes No (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
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Are you employed at the institution? [ lj; Do you receive any payment from the institution?
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast sthc months '
transactions l
2. Are you currently employed? El Yes E6
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
g 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 of the following sources?
a. Business, profession or other self-employment El Yes %
b. Rent payments, interest or dividends El Yes W/No
c. Pensions, annuities or life insurance payments E1 Yes fo
d. Disability or workers compensation payments E1 Yes
e. Gifts or inheritances El Yes N
f. Any other sources El Yes Q/Q
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—00009-GIVIS Document 1 Filed 01/05/2006 Page 2 of 2
AO 240 Reverse (Rev. I0/O3)
DELA\\'A.R.E (Rev. 4/05)
4. D0 you have any cash or checking or savings accounts? El Yes M
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
lll/{es El No
If "Yes" describe the property and state its value.
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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 information is true and correct.
DA E A SIGNATLHKE OF APP ICANT
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.