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

Case 1:07-cv—00759-SLR Document 1 Filed 11/26/2007 Page 1 of 2
I A0 240 (Rev. IO/U3)
DELAWA.REtRev. 4/05
‘ L UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Q; y. t it e ia ,4 r gg eco 1C;
Plaintiff APPLICATION TO PROCEED
V. _ WITHOUT PREPAYMENT OF
l\\t<~»\~$i*< Q? L (Q ry i Xi;€·€@lg FEES AND AFFIDAVIT
Defendant(s)
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I, di;) I-A U fe Q A E Q CCB li Q- declare that I am the (check appropriate box)
Cl Petition ovant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §I9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. .
Q} L;-J
In support of this application, I answer the following questions under penalty of perjury: ici
5
l. Are you currently incarcerated'? Cl Yes ®\T\Io (l`f"No" go to Question ’2)¤==:‘
If "YES" state the place of your incarceration ._q I
IE
Inmate Identification Number (Required): *3-
‘ sv
_ Areyou employed at the institution? i,,..... Do you receive any payment from the institfifion?
Attach a ledger sheet Qorn the institution of your incarceration showing at least the past srbc rnonths’
transactions
x
2. Are you currently employed? El Yes /§ No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer. _ _
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
. . salazorwages and pay period and the name and address of your last employer. 2 9* F Cl ci ‘F
i»‘is~f\x~\Ar~ < K\ t?1¤~0 6 Gr-? @r°2ct$?hrPr \ Qi:} P 5 ‘?°"+t>rt~€_€l<. ér·ip2e;rcD
3. In t ie past 12 twelve mon s have you received any money from any ofthe following sources?
a. Business, profession or other self-employment ¤ Yes El’NoI
A b. Rent payments, interest or dividends E1 Yes EI/N5
c. Pensions, annuities or life insurance payments E1 Yes P3/Wd
d. Disability or workers compensation payments Kit/Yes El No
_ e. Gifts or inheritances U Yes D3/No
f. p Any other sources I _ C El Yes lil/No
If the answer to any of the above is "YES" describe each source of money and state the amount i
received AND what you expect you will continue to receive.
— * ——- A r li ‘ Q GD we ir
I 3 5 IC€OQ\i*I ‘5<’¤¤~-“2·e¤t°r\l is MC-O M L Q 5 II i s

Case 1 :07-cv—00759-SLR Document 1 Filed 11/26/2007 Page 2 of 2
AO 240 Reverse (Rev, lth'03)
DELA`l’l'AR.EjRcv. 4/U5!
-4. Do you have any cash or checking or savings accounts? EK Yes El No
lf "Yes" state the total amount 33 QS
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ,
El Yes U lf "Yes" describe the property and state its value.
A 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. r
A A/ (Q /U
l declare under penalty of perjury that the above information is true and correct.
41 race 7
· DATE S GN OF APPLICANT n
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 1:07-cv-00759-SLR

Document 1

Filed 11/26/2007

Page 1 of 2

Case 1:07-cv-00759-SLR

Document 1

Filed 11/26/2007

Page 2 of 2