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

Case 1 :07-cv-00564-SLR Document 5 Filed 10/O4/2007 Page 1 of 2
Case 1:O7—cv—OO554-*** Document 4 Filed O9/27/2007 Page 2 of 3
AO 240 (Rin. l0/0])
DELAWARESRQV 5/06)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
'-i " ·.-_ . a.- .; ‘_ _ _ . .. _ FEES AND AFFIDAVIT
Defendant(s) ` _ » ~ y _
` CASE NUMBER: 07-564 » -l~
l, ,; t Q .. __ __ declare that l am the (check appropriate box)
It Petitloner/Plaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request lo proceed without prepayment of fees or cqsg under
28 USC §l9l 5, l declare that l am unable to pay the costs ofthese proceedings and that I am entitled to Lge relig§ET.·
sought in the compIaint/petition/motion. .;;,» §j¥'¥
I .
In support ofthis application, l answer the following questions under penalty of perjury: :_"(-‘1
. ‘<¤ t"¤i‘; A
l. Are you currently incarcerated? E Yes ’ No (If"No" go to Question 2) ·`
NJ _··
If "YES" state the place ofyour incarceration it A
Inmate Identification Number (Required): · U `
Are you employed at the institution? _ Do you receive any payment from the institution? in
Attach rt ledger sheet {rom the institution 0[ your incarceration detailing all transactions over t/ze gast
sth: months.
2. Are you currently employed? Cl Yes fh No
a. lfthe answer is "YES" state the amount ofyour tal and give the name and address ofyour employer.
b. lfthe answer is "NO" state the date of your last employment, the amount ofyour tal salary or wages and pay period and the name and address of your last employer. _ _
. 1 i.' .-. r }l·-·> - l-
1 . I- . I . _. `J._L ..,L{ .L.r.__ ..*:_-I`; |‘l;i.
3. ln the past l2 twelve months have you received any money from any ofthe following sources? ·iZ’."t'~* len ir; “- ‘{_
l_.-._._,s . il t..*"<
a. Business, profession or other selfemployment Cl Yes Cl-‘ No
b. Rent payments, interest or dividends G Yes Ei- No
c. Pensions, annuities or life insurance payments D Yes B No
d. Disability or workers compensation payments A Yes Ely No
e. Gifts or inheritances Cl Yes lit No
f. Any other sources Cl Yes ID No
[fthe 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-00564-SLR Document 5 Filed 10/O4/2007 Page 2 of 2
Case t:O7—cv-00564-*** Document 4 Filed O9/27/2007 Page 3 of 3
AO 240 Rcvcrsctllav 1010})
DELAWARE Rev S/Od!
4, Do you have any cash or checking or savings accounts? Ei Yes El No
If "Yes" state the total amount S, t. ‘
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property?
‘ Yes Cl No
lf "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.
l declare under penalty of perjury that the above information is true and correct.
D . ”>
DATE iS GNATURr OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment offees shall submit an affidavit
stating all assets. ln addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances d uring 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-00564-SLR

Document 5

Filed 10/04/2007

Page 1 of 2

Case 1:07-cv-00564-SLR

Document 5

Filed 10/04/2007

Page 2 of 2