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

_ Case 1:07-cv—00756-SLR Document 1 Filed 11/21 /2007 Page 1 of 2
AO 240 (Rev. lU,·' D3)
DELAWARE (Rev. 4[D5
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
;lo§g,‘g§ l50[iQg; `
rnmarr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
EQU Gw bdiyc FEES AND AFFIDAVIT
Defendant(s) _ .
CASE NUMBER: @(0970 [ Q"]
l, L · i’&) Q declare that l am the (check appropriate box)
° ° Petitione ovarit ° ° Other _
in the ab ove-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, l declare that l am unable to pay the costs of these proceedings and that l am entitled to the relief
sought in the complaint/petition/motion. ‘·- ·= _, , ;, _ 3, _ _ p,VA p A ___p_1 . _p;__ __ v_
....r»».teurr1 _Vy_ E if ri
In support of this application, I answer the following questions under penalty of . ? 1 W _,
l. Are you currently incarcerated? ° ° °No (lf "No" o to uestion 2) Lib
S g.._ . , r y y E
lf "YES" state the place of your incarceration STV} [I J pg
. -V-r.ae»;···;'h,_._,__ =Jr __`a:;r: _.: "rM,"w"-'Ej;`LI I * I
Inmate Identification Number (Required): GQ 3) • Sfctn AF
Are you employed at the institution? Q [gg Do you receive any payment from the instiuition? AE;
Attach a ledger sheet from the institution of your incarceration showing atleast the past six months’
transactions
2. Are you currently employed? ° °Yes ° ®
a. lf the answer is "YES" state the amount of your ralce—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 of the following sources?
a. Business, profession or other self-employment · • • No
b. Rent payments, interest or dividends · • Yes · • No
c. Pensions, annuities or life insurance payments · • Yes • • No
d. Disability or workers compensation payments • • Yes · · No
e. Gifts or inheritances • · Yes · · No
f. Any other sources · · Yes · • No
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 1:07-cv—00756-SLR Document 1 Filed 11/21/2007 Page 2 of 2
AO 240 Reverse (Rev. IU] D3)
DELAWARE Rev, ¢tfD5
4. Do you have any cash or checking or savings accounts? · • Yes ®
If "Yes" state the total amount $ _
5. Do you own any real estate, stocks, bonds, securities, other inancial instruments, automobiies or other
valuable property?
· • Yes (· •No)
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 rnuch you contribute to their support, OR state NONE if applicable.
Nvve
I declare under penalty of perjury that the above infomation is true and correct.
zig; 34} QOO7 r: QL
DATE IGNATURE OF 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 certified by the appropriate institutional
ofiicer 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-00756-SLR

Document 1

Filed 11/21/2007

Page 1 of 2

Case 1:07-cv-00756-SLR

Document 1

Filed 11/21/2007

Page 2 of 2