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

r Case 1 :08-cv-00002-JJF Document 1 Filed O1/O2/2008 Page 1 of 2
AO 24G (Rev. “l0_/03)
DELAWARE [Rev. 4505
UNITED STATES DISTRICT COURT ,_;_
° DISTRICT OF DELAWARE
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pl - arr APPLICATION TO PROCEED,
V. WITHOUT PREPAYMENT OE;
iggi,-g .Z A FEES AND AFFIDAVIT
Defendant(s) __ · "'
` — ·- CASE NUMBER: " O 8 O `
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_ ___ A L r ; [ 1 L,‘___ declare that I am the (check appropriate box)
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E Petitioner/Pl ' — ff/`Movant Cl Other
/ in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitionfmotion.
In support of this application, I answer the following qu tio s under penalty of perjury:
l. Are you currently incarcerated? El Yes (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? NbDo you receive any payment from the institution?
Attach a led er sheet om the institution o `ncarceration showin at least the ast six month!
transactions
2. Are you currently employed? Yes El No
a. lf 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
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment /2%
b. Rent payments, interest or dividends D Yes {N6
c. Pensions, annuities or life insurance payments El Yes D/No"
d. Disability or workers compensation payments El Yes
e. Gifts or inheritances El s
f. Any other sources Yes El No
lf the answer to any ofthe 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-OO0O2—JJF Document 1 Filed O1/O2/2008 Page 2 of 2
AO 14U Reverse (Rev. 10/O3)
DELAWARE Rev. ·lfU5l , I
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4. Do you have any cash or checking or savings accounts? El Yes
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If "Yes" state the total amount $ ’“ 5
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
D Yes
valuable property?
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 information is true and correct.
i DAT? i SiGN%,§RE OF APPLICANT Q S
NOTE T0 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 1

Filed 01/02/2008

Page 1 of 2

Case 1:08-cv-00002-JJF

Document 1

Filed 01/02/2008

Page 2 of 2