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

A n I Case 1 :07-cv—00839-SLR Document 1 Filed 12/21 /2007 Page 1 of 3
I AD 240 (Rev. IDIGJ)

I UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
'i 5- Ig 'G
l? ig; Qt i l l . A.C‘x1i· ‘;g’;{ cmg,
imnurr APPLICATION TO PROCEED
V. WITHOUT PREPAYMEN T OF
JE 5 ,5g"{ get-igg»ri..it' FEES AND AFFIDAVIT
Defend ant(s)
CASE NUMBER; Ml O Y " 8 3 9
I, _ _ , ,§_ QQ (jsfji declare that I am the (check appropriate box) I
E/i Petitioner/Plaintiff/Movant lj 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 tl1at I am unable to pay the costs of these proceedings and that I am entitled éprtlie relief
sought in the complaint/petitionfmotion. .
<"‘ ”"‘.-i .`l.
In support of this application, I answer the following questions under penalty of perjury: tj
l . Are you currently incarcerated? Cl Yes EQU (If "No" goto Question 2] E

If "YES" state the place of your incarceration
”_,._...' ii.
Inmate Identitication Number (Required):
Areyou employed at the institution'? Do you receive any payment from the institution?
Attach a ledger sheet Qom the institution of your inca.··ceration showing at [east the past six mor1ths’
transactions I
2. Are you currently employed? E-I Yes me
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. 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.
at 5 »*I·‘?‘»Pl-e:+si?i> I
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self—employment Q/Yes EI No
, b. Rent payments, interest or dividends El Yes 5*fNo
c. Pensions, annuities or life insurance payments I3 Yes IQ/lxlo
d. Disability or workers compensation payments E}/Yes III No
_ e. Gifts or inheritances EI/I Yes I3 No ‘
f. Any otlr sources _ EP/Yes III No
If 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 :07-cv—00839-SLR Document 1 Filed 12/21/2007 Page 2 of 3
AO 240 Reverse [Rev, lD.·'CI3]
DEL}L\VARE£Rev. 4J'Cl5
4. Do you have any cash or checking or savings accounts'? K2/ Yes U No
If "Yes" state the total amount $ 2,5,;
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ,
. ` i FE1/{Les F3 No .
. If‘"Yes" describe the property and state its value. ‘ _
r \ QQ¢£`—$!'Q`.i i_ I
i $5 gl _
L L 6. U 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. a
A 5 .l`*~·*'\`- f l>Awea‘ii§l3?.
·= ”*$2‘l€§/Nite} _
I declare under penalty of perjury that the above information is true and correct.
fa si sg · Q it .
’ P DATE SIGNATURE OF APPLICANT ·
, NOTE TO PRISONER: A 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
A _ institutions, attach oue certified statement of each account.

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Case 1:07-cv-00839-SLR

Document 1

Filed 12/21/2007

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Case 1:07-cv-00839-SLR

Document 1

Filed 12/21/2007

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Case 1:07-cv-00839-SLR

Document 1

Filed 12/21/2007

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