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

Case 1 :07-cv-00451-JJF Document 1 Filed 07/20/2007 Page 1 of 2
AO 240(Rev. lUlU3)
DELAWARE Rev. 4/05;
UNITED STATES DISTRICT COURT e' iL£1._i
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Plaintiff APPLICATION TO PROCEED
. V. r - A WITHOUT PREPAYMENT OF
E F0 tg" (IQ 1/\ JV K. . CC-IC @.i’i»*— FEES AND AFFIDAVIT
Defendant(s)
M7 Q ‘Hm CASE NUMBER: O T _ A 5 1
I, 2-/"OI»II—·fJ“&ILI““ IQ Ci I declare that I am the (check appropriate box)
ESV Petitioner/Plaintiff/Movant El 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/petitioii/motion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? lj Yes El/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? I/l0
Attach a ledger sheet ions the institution of your incarceration showing at least the gast six rnonths ’
transactions
2. Are you currently employed? lg/Yes El No
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a_ . . I
and give the name and address of your employer. 2, @9 FJ aé @4762 . £)$?»KClI/fl
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b. If the answer is "NO" state the date of your last employment, the amount of youi Ile-homeqi I
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment III Yes IEVEQ
b. Rent payments, interest or dividends Ei Yes E/No
c. Pensions, annuities or life insurance payments El Yes ID/fic
d. Disability or workers compensation payments ll Yes |E"l;lo
e. Gifts or inheritances Ei Yes
f. Any other sources El Yes IQ/No
lf the 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-00451-JJF Document 1 Filed 07/20/2007 Page 2 of 2
A0 240 Reverse (ILev. 10/U3}
DELAWA.R.E{Rev. 4/D5!
4. Do you have any cash or checking or savings accounts? E4{es El No
If "Yes" state the total amount $ i F QQ O
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
l2/ Yes
If "Yes" describe the property and state its value. » I r 0 G
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6. List the persons who are dependent on you for support, state your relationship to each person and
indicate hovv much you contribute to their support, OR state NONE if applicable. J [
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I declare under penalty of perjury that the above information 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. Ineaddition, 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.