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

Case 1 :07-cv-00660-Gl\/IS Document 1-2 Filed 10/22/2007 Page 1 of 2 `
‘ AO 240 (Rev, ID/O3)
DELAWARE Rev. 4/05 2
l
‘ UNITED STATES DISTRICT COURT _
DISTRICT OF DELAWARE O R l Gl N A L- j
Alicia C—a¤~tt<~¤t-l i I
Piamutr APPLICATION T0 PROCEED Y
B V. b WITHOUT PREPAYMENT OF
`I \-l`l*€/St" t STR? Fl nig Solgélt ¢t~—l·_Si FEES AND AFFIDAVIT
Defendant(s) __ l
‘ cassnumeaa; O i' —· *5 ti 0 I l
i
I, A; Hoo C kl iq G tsl declare that I am the (check appropriate box) l
mf Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of t`e§r coggtéiiuirder i
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am enti@d to§§§reliet` =
sought in the complaint/petition/motion. . 2
In support of this application, I answer the following questions under penalty of perjury: "§
;
i. Are you currently incarcerated? El Yes me (If "No" go to Question 2) lf? _
If "YES" state the place of your incarceration r ‘ I
. Inmate Identification Number (Required):
_ Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet fom the institution of your incarceration showing atleast the past six months ’
transactions l
2. i Are you currently employed? E/Yes El No , $ 2 6 O
C Ob Nr $·U·€’ul tr tr~\·G»0V'••'\‘€J ..B....;'L9'..Q
a. if the answer is "YES" state the amount of your take;home salary or wages and _p period a , . ,
{3 and give the name and address of your employer.5
WL, 0 0 Q Q- 3 l- ¤'7)·—{#e(, 1 o· o": - o"‘J ," . £I§q·=;.c;7,
b. It` the answer is "NO" state the date of your last employment, t e amount o __ our a e-home` _
salary or wages and pay period and the name and address of your last employer.
3. In the past 12 twelve months have you received any money from any ofthe following sources? l
a. Business, profession or other self-employment U Yes tghlo
b. Rent payments, interest or dividends E1 Yes No
c. Pensions, annuities or life insurance payments . U Yes lll, No
d. Disability or workers compensation payments tn Yes E] No
y e. Gifts or inheritances D Yes E! No
f. Any other sources · _ El Yes E! No
If the answer to any ofthe 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-00660-G|\/IS Document 1-2 Filed 10/22/2007 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARESRW 4/052 *
4. Do you have any cash or checking or savings accounts? E Yes IAM
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property'?
D Yes E/No p
If "Yes" describe the property and state its value.
i
l 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.
E, tc, 03 —-· my daughter
N 0 M6 .
‘ i U I declare under. penalty of perjury that the above infomation is true and correct.
ite-Mix},-en"} OVW? (gm- gm
· DATE SIGNATURE OF APPLICANT ·
NOTE To PRISONER: - A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. Inaddition, 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-00660-GMS

Document 1-2

Filed 10/22/2007

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Case 1:07-cv-00660-GMS

Document 1-2

Filed 10/22/2007

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