AO 240 (Rev. l0/03)
DELAWARElRev. 5/06)
UNITED STATES DISTRICT COURiI?l;f`ilf". `·° »`â€V;/, li
DISTRICT OF DELAWARE wm _
MM MAY 2 l PF? l2= SQ
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
(2% S7'ZgZ(g2° Ugg §F@77+ 5 gk mats, FEES AND AFFIDAVIT
/ Defendant?). _ d O "‘ 5- _
lgblz 0/% CASE NUMBER: -
I, Q3,-{ declare that I am the (check appropriate box)
IY Petitioner/ ovant U Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
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 complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
l . Are you currently incarcerated? El Yes me (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 all transactions over the gust
six? months.
2. Are you currently employed? mes El No · Q;/A
.1$*Jc»13,[, QA
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period lp LLL D
and give the name and addresggiyyqur employer. 3 f [qw,
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salary or wages and pay period and the name and address of your last employer.
i Mx .
3. In the past 12 twelve months have you received any money from any ofthe following sources? M} [qw!
Q @@5 "
a. Business, profession or other self-employment E1 Yes ¤2’ No {/@6*0 /1%/
b. Rent payments, interest or dividends El Yes RY No I/1MrA
c. Pensions, annuities or life insurance payments D Yes IY No jj [yan}?
d. Disability or workers compensation payments EI Yes {Y No /°;,fWU;/L
e. Gifts or inheritances D Yes df No
f. Any other sources El Yes Q/No
If the answer to any of the 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-00529—lV|PT Document 18 Filed 05/21/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/O3)
DELAWARE 1Bev 5/06:
4. D0 you have any cash or checking or savings accounts? Y2/Yes E1 No
» 0
If "Yes" state the total amount $ [ DQ gi"
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? p g
#292/Opp p/Yes El No
If "Yes" describe the property and state its value.
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6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how muchyou contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above information is true and correct.
W / .
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D TE 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.
Case 1:07-cv-00529-MPT
Document 18
Filed 05/21/2008
Page 1 of 2
Case 1:07-cv-00529-MPT
Document 18
Filed 05/21/2008
Page 2 of 2
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