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

Case 1 :O7—cv—OO734-GI\/IS Document 8 Filed O3/O3/2008 Page 1 of 2
i AO 240 (Revs l(1J'UJ)
DEL.•\WARE;{Rev, 4fUS
L UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE A I - -- P .
l Piaiilnrr APPLICATION TO PROCEED
6-if % V. WITHOUT PREPAYMENT OF
Cl, v O . fz FEES AND AFFIDAVIT
Defendant(s)
I cnsanomsaaz 0 ’?Cl/'73>‘/CUWS
I, · ‘ Q i . declare that I am the (check appropriate box)
E Petition r 1 ovant El Other
in the above—entitled proceeding; that in support of my request to proceed withoutprepayment ofifneies under
28 USC §19l5, I declare that I_am unable to paythe costseof these proceedings and that I am Glgiléd Eogthe relief
sought in the complaint/petition/motion. I . .
Egg; `T
In support of this application, I answer the following questny underpenalty of perjuryti . I i i
l. Are you currently incarcerated? El Yes i No l‘No" go to Question 2)
-:7 Qi`.
If "YES" state the place of your incarceration `
Inmate Identification Number (Required} - R R- a M _ · r I
Areyou employed at the institution? Do you receive any payment from the institution? tbl [I
Attach a lcd er sheet otn the institution o our incarceration showin at least the astsix n1onths’
transactions ` ‘ ‘ ‘ I " ‘ I
2. Are you currently employed? Ei Yes No is l `I``
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. i i
b. If the answer is "NO" state the date of your last employment, the amount of your takeehome _
sala or Waiilandiiay peri d ag Ile name and a renq war bit emnloyer.
(BCnril=R» 00 n ig 4 elim —0 0i Odeo I
3. In the past 12 twe ve months ha e o received any money m anlsypcyhe following sources?
a. Business, profession or other self—emp1oyment Yes C1 No
b. Rent payments, interest or dividends Ei Yes U No
c. Pensions, annuities or life insurance payments E1 Yes El No
d. Disability or workers compensation payments U Yes Ei No
e. Gifts or inheritances U Yes El No
f. Any other sources _ EI Yes E1 No
If the answer to any ofthe above is "YES" describe each source of money and state the amount
receive ND what ou expe tyou will con `n to receive. _ if
MF Qnplnjad I tgnrdéinn it 600 I MJ/Jl//J done M65
WJ 1 A A

Case 1 :O7—cv—OO734-Gl\/IS Document 8 Filed O3/O3/2008 Page 2 ct 2
AO 240 Reverse (Rev. lU»'d3) V
DELAWARE£Ecv. 4¤'05 `
4. D0 you have any cash 0r checking or savings accounts? U Yes El N0
if "Yes" state the total amount $
5. D0 you own any real estate, stocks, bonds, securities, other financial instruments, autom iles or other
valuable property?
' II! Yes No .
If "Yes" describe the property and state its value.
6. List the persons who are dependent 0n you for support, state your relationship t0 each person and
indicate how much you contribute t0 their support, OR state NOAE if applicable. 0
I declare under penalty of perjury that the above information is true a11d conect.
3 - 3 -O‘·i ..0.a.. at . 1.4, 0.; ,x l; [409.. 0 M 0
DATE U I I T AT Ni or APPLICANT -
NOTE TO PRISONER: T 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-00734-GMS

Document 8

Filed 03/03/2008

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Case 1:07-cv-00734-GMS

Document 8

Filed 03/03/2008

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