_ it AO 240[Rzv.10/(II) I , _ ,
~ v_ DELAWARE gev. 4/E ` ‘ I ‘ ,
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
t)€i}i‘•/ttl id llniteltiti
Piatntirr ‘ APPLICATION T0 PROCEED
6 _‘ S; . ` WITHOUT PREPAYMENT OF
" - i¥ J wl iii&rtF$ES AND AFFIDAVIT
Defend it(s)
t r\ )" CASENUMBER; t O T " T 3 ,4 _
- I ‘°" a ` J
I, */_ , L{b‘= i · declare thatlam the (check appropriate box)
° ° Petitioner/ aintiff/Movant ° ° Other l
in the above-entitled proceeding, that in support ofmy request to proceed without pr • · ·- a . .__ · ~ . •. __ under
28 USC §l915, I declare that I am unable to pay the costs ofthese proceedings an that am _'¤ r;-1 _=__ ji- relie H J
sought in the complaint/petition/motion. I l _— I
·`:
I f’ =· ii
In support of this application, I answer the following questions under penalty ofpe ury; L2 t`
· •_ _ O ui in I ' - -
1. Are you currently incarcerated? ® p°No glf No g • u iggg -§ mm;AR_--_-.—QI
y If"YES" state the place of your incarceration . -. t
Inmate Identilication Number (Required): Lf)
Are you employed at the institution? V Do you receive any payment from the institution?
Attach a /ea/ger sheet from the institution 0/ your incarceration showing at least the gas! silt months'
transactions _` -
2. Axe you currently employed? ° ° Yes .
a. Ifthe answer is "YES" state the amount of your tal
b. If the answer is "NO" state the date ofyour last employment, the amount ofyour take-home
salary or wages and pay period and the name and address of your last employer.
3. t In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self—employment · • Yes · •
b. Rent payments, interest or dividends • • Yes • · o `
c. Pensions, annuities or life insurance payments · · Yes · • i i
d. Disability or workers compensation payments • • Yes • ·. _
e. Gifts or inheritances · • Yes • •
f. Any other sources • • Yes • _f'
If the 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.
Case 1:07-cv—00734-Gl\/IS Document 1 Filed 11/16/2007 Page 2 of 2
AO 240 Reverse (Rev, IO/OC3}
DELAWARE rilev l/05) ,
4- D0 you have any cash or checking or savings accounts? ° ' Yes
If"Yes" state the total amount 5 ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instmments, automobiles or other
valuable property? ‘ ‘·--\
· • Yes
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 much you contribute to their support, OR state NONE if applicable.
I declare under penalty of perjury that the above information is true and correct.
a ‘ i g
-—/ - —~ C-\ ° 5 _` "X
’ , Z ¤ /_ l' `
DATE - SIGNA URE 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
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 ofeach account.
Case 1:07-cv-00734-GMS
Document 1
Filed 11/16/2007
Page 1 of 2
Case 1:07-cv-00734-GMS
Document 1
Filed 11/16/2007
Page 2 of 2
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms