AG 246 (DEl.A\VA.RE R.E\’ 7.00) _ V I ' I
UNITED STATES DISTRICT COURT" T` y ` .
_ __ ,7 [ DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
V. ` FEES AND AFFIDAVIT
dt? . ·
Defendant(s) CASE NUMBER; [ ff O{,L__ C V- O0 I
•. K`) `
L- lik] _ declare that I am the (check appropriate box)
£tioner/Plaintiff/Pvlovant K] 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 arn l
unable to pay the costs of these proceedings and that I am entitled to the relief sought in the p
comp 'nt/ motion. l 1
In support of this application, I answer the following questions under penalty of perjury; i
1. Are you currently incarcerated? o (If "No" go to Question 2) _ I 1
If "YES" state the place of your incarceration 5 ci 1 ""I nrli I
Are you employed at the institution'? l D Yes M ‘ { 1
p I I @EC I Q 2607
Do you receive any payment from the institution? E Yes lQ#I
Have the institution tl! our me cer-ri'r?enta norrion of:/its nfridnvir and )_r: ; ,$ital_' $.15.. wi; - it
insrimrion/rl of min- incnrcemrinn showing nr feast the nerr SIX monrhy rrrmsnctions. Ledeer QU ,
sheets are no? required for cose: r'Ir’en’ _Qur·sz.·cmt to 28.·U5`C’ §2254. Qramfu
2. Are you currently employed? CI Yes E}/N?/rf iiii H
I a. lf the answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address of your employer. Af / Q _
b. lf the answer is "NO" state the date of your last employment, the amount of your talre-home
salary or wages and pay period and the name and address of your last employer. Ay /,{/2
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business. profession or other selt`·employrnent l El Yes EQ
b. Rentpayments, interest or dividends C] Yes
c. Pensions, annuities or life insurance payments E] Yes
d. Disability or workers compensation payments . D Yes Eye .
e. Gifts or inheritances D Yes 2%/
l`. Any other sourcps D Yes No
If th answer to any ofthe above is "YES" describe each source ofmoney and state the amount
received AND what you expect you will continue to receive.
’ . » j Case 1:07-cv-00749-JJF Document 11 Filed 12/19/2007 Page 2 of 2
Do you have anyi cash or checking or savings accounts? E Yes QJ · . _ Q
1
If "Yes" state the total amount S i - <
5. ‘ Do YOU OWI1'Ei!'1y FEB.] GSIEIE, stocks, lJOI"tdS., S€CL11’]i`{`l€S, O[l'1EI` HI'lEIl’lClEi l1’l$II'LtIT1€I1[ L1IOTHObll€S Oi' _
other valuable properqr? lj Yes L
lf "Yes" describe the property and state its value. H E
JJ A Q
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. ·
el M »
I declare under penalty of perjury that the above infomation is true and correct. b
Date; JDJ / Signature ofApp1icant
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E 1
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SEE ATTACHED “
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SIX MONTH STATEMENT 1
Case 1:07-cv-00749-JJF
Document 11
Filed 12/19/2007
Page 1 of 2
Case 1:07-cv-00749-JJF
Document 11
Filed 12/19/2007
Page 2 of 2
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