IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE In the Matter of: OR ____________________________________ C.A.# C.M.# APPLICATION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS Under penalty of perjury, I declare that all of the following information is true and correct in support of this application to proceed in the above-captioned matter without paying Court fees and costs, or give security therefore. I understand that a false or incomplete statement may result in a dismissal of my claims or an order requiring immediate payment of all costs in addition to a monetary penalty. Instructions: Complete all questions in this application and then sign it. Do not leave any blanks; if the answer to a question is "0," "none," or "not applicable (N/A)," write that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case caption, and the question number. Because of my financial situation, I am unable to pay the costs of this proceeding or give security therefore. In support of that statement, I supply the following information: 1. Are you employed? YES NO Self-employed IF "YES": a. Name and address of employer: b. How often paid: c. Take home pay per pay period: IF "NO" a. Name and address of last employer: b. Date of last employment: c. Take home pay per pay period: 1 American LegalNet, Inc. www.FormsWorkFlow.com List ALL income you have received from any source within the last 12 months and identify the source if it is not listed on the table below. (Attach additional pages if necessary.) HOW OFTEN WHEN RECEIVED SOURCE OF INCOME AMOUNT RECEIVED (one time or regular) Business, profession or self-employment Rental income Interest Dividends from stocks or bonds Retirement or annuity payments (i.e. disability, social security etc.) Bank account interest Unemployment benefit payments Other: _____________________________ 3. Do you have a spouse? YES NO ("Spouse" includes domestic partner or party to a civil union). If you have a spouse, list ALL income YOUR SPOUSE has received from any source within the last 12 months and identify the source if it is not listed on the table below. (Attach additional pages if necessary.) HOW OFTEN RECEIVED (one time or regular) 2. 4. SOURCE OF INCOME Business, profession or self-employment Rental income Interest Dividends from stocks or bonds Retirement or annuity payments (i.e. disability, social security etc.) Bank account interest Unemployment benefit payments Other: ____________________________ AMOUNT WHEN RECEIVED 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. List ALL property owned, whether held in your name alone or jointly with anyone else. (Attach additional pages if necessary.) IF OWNED JOINTLY NAME AND ADDRESS PROPERTY VALUE OF JOINT OWNER Cash Bank Accounts Stocks or Bonds Automobile and other vehicles Real Estate (other than your primary residence) Other valuable property (except ordinary household furnishings and clothes) Other: _____________________________ 6. List ALL debts and monthly expenses. (Attach additional pages if necessary.) MONTHLY PAYMENT DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS TOTAL DEBT 7. List names and addresses of all dependents, persons you actually support, (children or other) and their relationship to you. (Attach additional pages if necessary.) AGE RELATIONSHIP TO YOU DEPENDENT'S NAME AND ADDRESS 3 American LegalNet, Inc. www.FormsWorkFlow.com 8. IF YOU ARE INCARCERATED, complete all parts of Question 8. If you are NOT incarcerated, do not complete Question 8 and proceed to Question 9. a. ATTACH a Department of Correction certified statement of your inmate account that includes all account activity for the 6-month period immediately before the filing this application, OR for the entire time you have been incarcerated, whichever time is less. At any time while incarcerated or detained at any facility, have you previously brought an action or an appeal in a federal court or in any court in this State? YES NO b. If "YES" complete the table below (Attach additional pages if necessary): CIVIL ACTION OR APPEAL NUMBER OUTCOME OF CASE OR APPEAL NAME OF COURT c. If your complaint relates to a condition of confinement, you MUST have fully exhausted all administrative remedies available through the institutional grievance procedure. Have you exhausted all administrative remedies? YES NO If "YES" ATTACH copies of all decisions in the administrative process. If "NO" do not file the complaint in this matter or this application. 9. Have you previously filed an application to proceed in forma pauperis in the Court of Chancery? YES NO If "YES" state the case number(s) and outcome(s) of your previous application (Attach additional pages if necessary): __________________________________ __________________________________________________________________ __________________________________________________________________ 10. Provide any other information that will help explain why you cannot pay the costs of these proceedings. _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. Provide the following information: Your current address: ______________________________________________________ Your daytime phone number: _______________________________________________ Your date of birth: ______ Your level of education: ____________________________ Last four digits of your social security number: _________________________________ I, , swear or affirm that all of the above information is true and correct and is made under penalty of perjury. SIGNATURE: DATE: I understand that if the Court directs that I pay certain fees and court costs but dismisses my complaint or claim, the Court keeps the power over me until all costs and fees are paid. SWORN TO AND SUBSCRIBED before me on this date: Notary Public or Court Clerk 5 American LegalNet, Inc. www.FormsWorkFlow.com