J AO 24B (Rev.1B/G3) i § § g
DELAWARE ' v. 4 05 I . . .. ...,.,.,...,..,., ..
UNITED STATES DISTRICT COUR DCI l 5 ZCGY
I DISTRICT OF DELAWARE Qi
‘ U.S. DISTRICT COURT
NINA seams, Plaintiff .. UISTIIICI Ot D UWV RE s....
Plaintiff APPLICATION T0 PROCEED i
V. WITHOUT PREPAYMEN T OF -
STATE OF DELAWARE FEES AND AFFIDAVIT _
Defenda1tt(s) _ _ Q
CASE NUMBER: `£‘ . 3 E
In Nina Shahint Plaintif f declare that I am the (check appropriate box)
© ° Petitioner/PlaintifB’l\/lovant f ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under j
28 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 complamdpetition/motion. _
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° Yes G °N0 (lf "No“ go to Question 2) i
If “YES" state the place of your incarceration l
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment korn the institution?
Attach a ledger sheet [rom the institution ot your incarceration showing at least the gast six months ’ T
transactions I
2. Are you currently employed? ° ° Yes © No I
a. Ifthe 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. {
b. If the answer is "NO" state the date of your last employment, the amount of your take—hpme
salary or wages and pay period and the name and address of your last employer. q/[{7 @95 g
3. In the past 12 twelve months have you received any money from any of the following sources'? if gm`) Gb
a. Business, profession or other selfemployment • • Yes G • No U ( E
b. Rent payments, interest or dividends • • Yes @• No gyda]
c. Pensions, annuities or life insurance payments • • Yes (B- No 1 '* T
d. Disability or workers compensation payments • • Yes E) · No ZLLQQJ
e. Gifts or inheritances · · Yes (E)- No
f. Any other sources • • Yes @ • No y
T
Ifthe answer to any of the above is "YE S" describe each source of money and state the amount
received AND what you expect you will continue to receive. =
» ‘ Case 1 :07-cv-00643—G|\/IS Document 1 Filed 10/16/2007 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARE In
4. Do you have any cash or checking or savings accotmts? (9* Yes • •No E!
g . QH Q:OH;Q_*'h_ `-LeL»J
It'"Yes" state the total amount $ &;`g`£ gm, , 9; @’vet,, 7 O ( pim,
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other pr [ GO
valuable roperty? ( E ·-
GJU2, Gm; LL. V‘~#G»*¥vc1.» vg ••Yes ••No OW M.! ‘·
`lf"Yes" de `be the property and state 1ts value. Q0* (JQ KJQQ
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. _
D TE SIGNATURE OF APPLICANT i i
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit 1
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. i
If you have multiple accoimts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.
Case 1:07-cv-00643-GMS
Document 1
Filed 10/16/2007
Page 1 of 2
Case 1:07-cv-00643-GMS
Document 1
Filed 10/16/2007
Page 2 of 2
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