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

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Case 1 :08-cv-00264-JJF Document 1 F ed /05/2008 Pagi]1 of 2
I 1 MAY - 5 2000 ll
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Prarmirr APPLICATION TO PROCEED
rg V. S Q WITHOUT PREPAYMENT OF
FCCJ * · { FEES AND AFFIDAVIT
Defendant(s)
I CASENUMBER: *08-2QSA
I, Q §\,Dg Qi Q Q Q ggg;(\© (JE fs declare that I am the (check appropriate box)
° ° Petitione ovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §19l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complairrt/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceratio g gg gym >§`gg»’\gA Lgéi x &[LgvL
Inmate Identitication Number (Required): OQ LBS S 2 [ 3
Are you employed at the institution? N_Q__ Do you receive any payment from the institution? QQ
Attach a led er sheet om the institution o our inca ce ation showin at least the ast six mont '
. · 1 1 .0 at test § · .
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2. Are you currently employed? ° ° Yes @ Q)er>~"<3¤\¤,».»\ Dc\Gt¤i>0u~;, \C&O\¤W
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a. lf the answer is "YES" state the amount of your take—home salai§y2>r 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 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment • · Yes
b. Rent payments, interest or dividends • · Yes
c. Pensions, annuities or life insurance payments • • Yes {EI
d. Disability or workers compensation payments • · Yes am
e. Gifts or inheritances · · Yes @
f Any other sources · · Yes QQ
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 :08-cv-00264-JJF Document 1 Filed 05/05/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARE tgev. 4£(B!
4. DO YOU have ally 08Sh Of Ch€CkiIlg OI S3.VlI'lgS EICCOUHYS? ' ' Yes
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other fmancial instruments, automobiles or other
valuable property?
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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.
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I declare under penalty of perjury that the above informatio is true and correct.
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DATE ’ IGNATURE OF APP CANT
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
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.

Case 1:08-cv-00264-JJF

Document 1

Filed 05/05/2008

Page 1 of 2

Case 1:08-cv-00264-JJF

Document 1

Filed 05/05/2008

Page 2 of 2