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

9 ` Case 1 :08-ov-00173-JJF Document 1 Filed O3/26/2008 Page 1 of 2 ° ‘
AO 2·i¤0 {Rev. `10lD3) K I n A
DELAWARE lEev. 4[D5] · _ ` ' - l . - .
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
_ Piamiirr APPLICATION T0 PROCEED
V. WITHOUT PREPAYMENT OF .
FEES AND AFFIDAVIT
Defendant(s) .
CASE NUMBER:
. - -. ·; T 3
Bl O Q
I, 0 Q. _ . » IW declare that I am the (chec appropriate box)
@Petitioner/Pla.intiffi’l\./lovant ° ° Other
inthe above-entitled proceeding; that in support of my request to proceed without pre at - _· A--- a t ···h·
28 USC §1915, I declare that I am unable to pay the costs of these proceedings an that I a _ _
sought in the complaint/petitionfmotion. '``` ` `J=` " ''`l' l All A H I = `hnl
· llall 2 Gailldtl
In support of this application, I answer the following questions under penalty of perj : U p kg _
1. Are you currently incarcerated? ° °No (If “No" go --J-__ I
’ If "YES" state the place of your incarceration d E?;E;g_.¤N%
Inmate Ideniiiicaiion Number (Required): 0 Q
Are you employed at the institution? Do you receive any payment from the institution? no I
I Attach a ledger sheet Qorn the institution of your incarceration showing at least the gast six rn0nths’
transactions
2. Are you currently employed? ° ° Yes ° No
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. Ifthe 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
a. Business, profession or other se1f—employment • • Yes @>
b. Rent payments, interest or dividends · · Yes
c. Pensions, annuities or life insurance payments ' • Yes
d. Disability or workers compensation payments • · Yes
e. Gifts or inheritances * • Yes
f. Any other sources • • Yes I
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-00173-JJF Document 1 Filed O3/26/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/ D3] .
DELAWARE $5ev. 4:'[|5 ` .
i 4. Do you have any cash or checking or savings accounts? • • No
If"Yes" state the total amount S [ lll QQ Q5 1
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
• · Yes :•._Q>l§
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.
Ygsytwiio qatsem choo s-
I declare under penalty of petjuzy that the above infomation is true and correct.
3i/itgiog . ._. ,, i... [ _
D TE · TURE or 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 certitied by the appropriate institutional
ofticer 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-00173-JJF

Document 1

Filed 03/26/2008

Page 1 of 2

Case 1:08-cv-00173-JJF

Document 1

Filed 03/26/2008

Page 2 of 2