AO 240 (Rev. l0iD3) . i LI.; ll \
DELAWAR.EtRev. 4.*05}: _ i I V-·-’ ( )
UNITED STATES DISTRICT COURT ii _! I
DISTRICT OF DELAWARE rc
/0\l`l"O[Q• ( ;Q;;l.t-l·Gt~L
I Plaintiff APPLICATION TO PROZQEEQ;
v. WITHOUT PREPAYMENT on-r=
A Qi, ?/QQO {fl'., A l s FEES AND AFFIDAVIT
Defendant(s) M pi 9
` CASE NUMBER: D i tr is- 5 ·
I, & O Q C Q {NX l\\ G jg declare that I ain the (check appropriate box)
M PetitionerlPlaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
23 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. I
In support of this application, I answer the following questions under penalty of perjury: V
l. Are you currently incarcerated? Cl Yes lg/No (lf "No" go to Question 2)
If "YES" state the place of your incarceration I `
. Inmate Identification Number (Required):
I Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qoin the institution of your incarceration showing at least the past six rnonths ’
transactions i
2. Are you currently employed? Y E/Yes El No _ _
g _ g » Qa¤~n~ma\t.4c¤m©"l*_Z·_B_‘.E.·;99.
` a. If theianswer is "YES·‘ state the amount of your take-home alary or wages and a erigd a -
_ and give the name and address of your employer. C§Sg:i·%‘l:'\_C( if gn I OL
41 eaten (coat- @79+0 (Jaw ew~·—
b. If the answer is "NO" state the date of your last employment, the amount of your t e—home IJQU) CHSIW
salary or wages and pay period and the name and address of your last employer. I D0- loci 769/
3. In the past l2 twelve months have you received any money from any of the following sources? I
a. Business, profession or other self—employment EI Yes l!( No
b. Rent payments, interest or dividends I3 Yes V No
c. Pensions, annuities or life insurance payments El Yes |l{ No
d. Disability or workers compensation payments E1 Yes B! No
e. Gifts or inheritances E1 Yes ll No
f. Any other sources U p [Z1 Yes rt', No
If the answer to any of the above is "YES " describe each source of money and state the a1nount
Y e received AND what you expect you will continue to receive.
Case 1:07-cv-00659-Gl\/IS Document 1-2 Filed 10/22/2007 Page 2 of 2
A0 240 Reverse (Rev. 10/03) I
DELAWARE {Rev. 4/U5! I
4. Do you have any cash or checking or savings accounts? U Yes Mts
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
IZ! Yes Q/No .
If "Yes" describe the property and state its value.
A 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, lc. \/\l· · Wx y <.\cm3vr\·c<"
zi C,oa—i"l"t"l b¤,"l“€, O · 0 O
I declare under penalty of perjury that the above information is true and correct. __
Y )
l 0 -· ‘l,’lJ 'O'] Qotm On.4\,y\gV]
i DATE SIGNATURE OF APPLICANT I
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-00659-GMS
Document 1-2
Filed 10/22/2007
Page 1 of 2
Case 1:07-cv-00659-GMS
Document 1-2
Filed 10/22/2007
Page 2 of 2
United States Free Forms
Canada Free Forms
United Kingdom Free Forms
Australia Free Forms