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

Case 1 :08-cv-00500-l\/ILC Document 1 Filed 08/08/2008 Page 1 of 2_ `
AO 240 (Rev. 10/03)
DELAWARE Bev. 4{05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Piamttrr APPLICATION TO PROCEED
V. S) \VITHOUT PREPAYMENT OF
C0•'\v’l€V L&U¤> {0* QQ wl |* l/GUI FEES AND AFFIDAVIT
Defenda t(s) »
CASE NUMBER; L-} ..
I, Q Lt Y` 1 $ i'\€# { VU€,l*\@l€{ declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, eclare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the c mp ain etition/motion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° ° °No " (If "No" go to Question 2)
{ / . I ( " AS
If "YES" state the place of your incarceration 0 GUM G C0 r/afro ncl I { i
Inmate Identification Number (Required); 7
[Ul [
Are you employed at the institution? 09 Do you receive any payment from the institution? O
Attach a ledger sheet Qom the institution of your incarceration showing at least the gas! six months '
transactions
2. Are you currently employed? ° ° ° w
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
_ s lary or wages and pay period and the name and a dress of yo las employer. Q., 4 _
,Q\{( MEG BIOS .. L·R¢\-it- 1 O1 l
3. the past 12 twelve months have you received any money from any o the ollowing sources?
a. Business, profession or other self-employment • • Yes • • tw
b. Rent payments, interest or dividends • · Yes • §
c. Pensions, annuities or life insurance payments • • Yes · • @
d. Disability or workers compensation payments • • Yes • · @[0
e. Gifts or inheritances • • Yes • • )
f. Any other sources • • Yes • •
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 o receive.
G/ILLO MULCLH —— in/arr - ·-l 08
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Case 1 :08-cv-00500-l\/ILC Document 1 Filed 08/08/2008 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? • •
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
· · Ye @
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.
/Ua M 5
I declare under penalty of perjury that the above information is true id correct.
éATE SIGNATURE OF 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 certitied
statement of each account.

Case 1:08-cv-00500-MLC

Document 1

Filed 08/08/2008

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Case 1:08-cv-00500-MLC

Document 1

Filed 08/08/2008

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