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

Case 1 :08-cv-00240-SLR Document 1 Filed O4/25/2008 Page 1 of 2
AO 240 (Rev. IO/03)
DELAWARE Rev. 4{OSZ _
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
%Q.»U I Q-VSGA
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
ETA L FEES AND AFFIDAVIT
Defendant(s) A A A
CASE NUMBER: O P T
I, YZ U l vu Q BQ —/ C. S est AJ declare that I am the (check appropriate box)
° ° Qetitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepa t of fees rFc§ 2
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that am I · if • ‘ · a t it l · ‘· g
sought in the complaint/petition/motion. i q p { 2
i APR Z 5 ZUU8
In support of this application, I answer the following questions under penalty of perjury: - ;;·—-mm. at
|STRlCl`CflC;;Â¥t! fum
l. Are you currently incarcerated? {_Yes7 ° °No (If "No" go to Qu ' % WAR
If "YES" state the place ofyour incarceration Q ·€t\ Q M { gi T g . Q 0 { F tf Cixi 1 W to W C =¢? *\\& Q {E
Inmate Identification Number (Required): lt 5 (7 S L
Are you employed at the institution? N U Do you receive any payment from the institution? IU G
Attach a ledger sheet from the institution of your incarceration showing at least the gas! six months’
transactions
2. Are you currently employed? ° °Yes ( N6 Y
a. If the answer is "YES" state the amount of your take—h0me 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- ome
salary or wages and pay period and the name and address of your last employer. iv W
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 • No E
b. Rent payments, interest or dividends • • Yes · • o`
c. Pensions, annuities or life insurance payments · • Yes • •
d. Disability or workers compensation payments • · Yes • ·
e. Gifts or inheritarrces · · Yes · · `
£ 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 to receive. I

Case 1 :O8—cv-OO240—SLFl Document 1 Filed O4/25/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/ (B)
DELAWARESRev. 4£05!
4. Do you have any cash or checking or savings accounts? • · Yes • ®
If "Yes" state the total amount S /1/ [ &
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• · Yes • @9
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.
QHY; 5* 6 /j..¢ZxvL/cog,
D . E SIGN RE 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 certified
statement of each account.

Case 1:08-cv-00240-SLR Document 1-2 Filed O4/25/2008 Page 1 of 1
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VICES OFFICE
MEMORANDUM
To.- yp Q4 ,gg>/LsE1#.- [S QS {QQ 2
FROM: Stacy Shane, Support Services Secretary
RE: 6 Months Account Statement
DATE: Q @@1 [3 g 1 K-Q5 Q Q5}?
ttached are copies of your inmat account statement for the months of
E 1 , to (E 13 g 2;; pes, Q; 24.
(
T he following indicates the average daily balances.
MONTH AVERAGE DAILYBALANCE
@;;Lm_ M
Average daily balances/6 months: gl
Attachments
CC; File
I ‘\
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