Free Letter - District Court of Delaware - Delaware

Case 1 :05-cv-00013-GIVIS Document 32-2 Filed 03/31 /2006 Page 1 of 2
AO 240 (Rev. ll}/(B1
Dl€l..\\\'-\llEtRcv. 4/OSN
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Wn no FC &'"t.»U { S
Plaintiff APPLICATION TO PROC EED
_ V. g WITHOUT PREPAYMENT OF
ids/2/1L6’¢» W'! Ll I/HWY . eercg z. . FEES AND AEE11>Av1T
Defendant(s) _ ‘ y
_ CASE NUMBER; 05 MU! 3 [em S
I, é Q;//Y’n"*·-€» g ZE declare that I am the (check appropriate box)
Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support ofmy 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 iat am erFt { Lo q- ie
sought in the complaint/petition/motion. ` ‘
in SUPPOIT 0f[hi$ Bppliwtion, I answer the t`e1lO $[iOnS under penalty Ofpcrju ,, l > .· -` 2
l. Are you currently incarcerated? ° es ° •N0 (Il`"N0" 20 to U€SU0Iy_ _|3;3`i?;Q`EiE§r)U|q‘|‘
_ DIST ICT OF DIF WAFIE _ _
If"YES" state the place of your incarceration C .C €”‘*//ZN/I F gg) g eau-—ir·<·¢f
Inmate Identification Number (Required): 2 Ze
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet [rom the institution of your incarceration showing at feast the gas! sit months ’
transactions I/'
2. Are you currently employed? ° ° Yes ° No
a. Ifthe answer is "YES" state the amount of your tal and give the name and address of your employer. -0%
b. If the answer is "NO" state the date of your last employment, the amount of your taI salary or wages and pay period and the name and address of your last employer. F-__
ti/; fyaz Mi z·/5 ::0 wh, `Dc»·r¤m¤¤_s?tN¤‘fn=1v» r/I 245 Mvrmrvo EL up Mruwk MJ Nel
. In t e past 12 twelve months have you received any money fiom any ofthe following
a. Business, profession or other self—employment • • Yes lylo
b. Rent payments, interest or dividends · • Yes ,/+6
c. Pensions, annuities or life insurance payments · · Yes fd
d. Disability or workers compensation payments · · Yes Y/No'
e. Gifts or inhentances • • Yes 2%
f. Any other sources • • Yes No .
Ifthe answer to any ofthe above is "YES" describe each source ofmoney and state the amount
received AND what you expect you will continue to receive.

Case 1:O5—cv—OOO13-Gl\/IS Document 32-2 Filed O3/31/2006 Page 2 of 2
AO 240 Reverse (Rev. IO/O3)
DEL/\WARE (Rev. J£O5l
4. D0 you have any cash or checking or savings accounts'? • • Yes J
It` "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? IK
° • Yes • o
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 ofpeijury that the above infomation is true and correct.
Bgaegog Q/""*·*>~¤»€ eHt;¤
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit antaffidavit
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.