IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
PAMELA J. BERGMANN, )
Plaintiff, i
v. i Civil Action No. 07-564-***
DJBWCI MEDICAL DEPARMENT, i
AND MS. RICHIE (C.O. Guard), )
Defendants. i
ORDER
At Wilmington this Jégklday of j%§j&£kégf/ , 2007,
the court having received subject complaint, which was not
accompanied by either prepayment of the entire $350.00 filing
fee, or in lieu thereof, an application to proceed without
prepayment of fees under 28 U.S.C. § 1915;
IT IS ORDERED that:
The plaintiff shall, within twenty—one days from the
date of this order, either; (1) complete and return an
application, or (2) pay in full the $350.00 filing fee.
Failure to timely comply with this order shall result
in dismissal of this case without prejudice.
%"? 7.% .
ited tates Magi te Judge
\
Case 1:07-cv-00564-SLR Document 4 Filed O9/27/2007 Page 2 of 3
AO 240 (Rev. IOIO3)
DELAW.¤.R.E$Rev 5/06
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Piamarr APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: O7—564
I, declare that I am the (check appropriate box)
El PetitionertPlaintiff/l\/Iovant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitionfmotion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? El Yes E No (If "No" go to Question 2)
If"YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution'? Do you receive any payment from the institution?
Attach a ledger sheet [rom the institution of your incarceration detailing ali transactions over the gas!
six months.
2. Are you currently employed? El Yes EI No
a. Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period
and give the name and address ofyour employer.
b. Ifthe answer is "NO" state the date of your last employment, the amount of your tal
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment El Yes Q No
b. Rent payments, interest or dividends Cl Yes El No
c. Pensions, annuities or life insurance payments D Yes EI No
d. Disability or workers compensation payments El Yes El No
e. Gifts or inheritances E1 Yes ¤ No
f. Any other sources El Yes El No
Ifthe 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 4 Filed O9/27/2007 Page 3 of 3
AO 240 Reverse (Rev 10/03)
DELAWARE Rev SJD6
4. Do you have any cash or checking or savings accounts? D Yes El No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes El No
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 infomation is true and correct.
DATE SIGNATURE 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 of each account.
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