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

Case 1 :08-cv-00002-JJF Document 5 Filed 01/31 /2008 Page 1 of 2
AO 2¢1U(R.ev. IDIUB)
DELAWA.R.EtRev, 4/05]
‘ i UNITED STATES DISTRICT COURT
` DISTRICT OF DELAWARE
H _ aA_ ._u l
ismnrr APPLICATION TO PROCEED
Q p ` V. / ® · WITHOUT PREPAYIVIENT OF
' I ’ _ . G?/LSL FEES AND AFFIDAVIT
Def d IR Q _ _
\ ` r ` NUMBER: OXCM
I, l A, I I A __.j.___ _ ·e ; that I am the (check approp1:§te
Petitioner/Plaintiff/Movant El Other QZ
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in the above-entitled proceeding; that in support of my request to proceed without prepayment of fee_s¤ or
28 USC § 1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled
sought in the complaint/petition/motion. . .{{_·
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In support of this application, I answer the following questi s under penalty of perjury:
l. Are you currently incarcerated? El Yes No (If "No" go to Question 2)
If "YES" state the place of your incarceration U . `
Inmate Identitication Number (Required):
Areyou employed at the institution? IU I |Do you receive any payment from the institution?
Attach ci led er sheet one the institutio o our incarceration showin at least the ast six rnonths’
rmnsacrions O O ~ - l 35 Cp I M gf-
2. Are you currently employed? Yes El No _ OQ
U GW V i+ So 1 ye 2
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 addressof 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
a. Business, profession or other self-employment es El No
b. Rent payments, interest or dividends U Yes No
c. Pensions, annuities or life insurance payments E1 Yes o
d. Disability or workers compensation payments IJ Yes No
e. Gifts or inheritances U Yes o
f Any other sources y U Yes Cl o
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 :O8—cv-OO0O2—JJF Document 5 Filed O1/31/2008 Page 2 of 2
AO 240 Reverse (Rev. ID/U3)
DELAWARE Rev. dr'05)
4. Do you have any cash or checking or savings accounts? Cl Yes yblo
If "Yes" state the total amount $ I
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? -
CI Yes No
if "Yes" describe the property and state its value.
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6. List the persons who are dependent on you for support, state your relationship to eag:%p¤Q{sb1i’(anc£`é’k ‘ '
indicate how much you contribute to their support, OR state NONE if applicable.
@ii?“ i?‘rt’“
I declare under pen ry that the above information is true and correct.
DAXIE i g1G;liATURE OF APPLICANT Y
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-00002-JJF

Document 5

Filed 01/31/2008

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Case 1:08-cv-00002-JJF

Document 5

Filed 01/31/2008

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