COURT OF COMMON PLEAS ffoorr tthhee SSttaattee OOff DDeellaawwaarree AAFFFFIIDDAAVVIITT IINN SSUUPPPPOORRTT OOFF AAPPPPLLIICCAATTIIOONN TTOO PPRROOCCEEEEDD IINN FFOORRMMAA PPAAUUPPEERRIISS http://courts.state.de.us/commonpleas/ >>>> 2 AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS* I, ______________________________, being first duly sworn, depose and say that I am the ___________________ (Plaintiff or Defendant) in the matter of ________________________________________. In support of my motion to proceed without paying Court fees and costs, or give security, I state: My date of birth is: ____________________ My current address is: _______________________ ________________ ________________________________ _______ Because of my financial situation, I am unable to pay the costs of this proceeding or give security. In support of that statement, I supply the following information: l. Nature of claim or defense is: __________________ ______________ ____________________________________ ____________________ 2. Are you presently employed? Yes_____ No_____ (If your answer is no, please skip to question 4) 3. If Yes, state: a. The name and address of your employer: ________________________ ________________________ ______________________________________ __________ b. State how often you are paid: ________________________ ________________________ c. State the amount of your take home pay per pay period: >>>> 3 ________________________ ________________________ 4. If you are not employed, state: a. Name and address of last employer: ___________________________ ______________________ b. Location and date of last employment: ___________________________ ______________________ 5. State whether you have received any income (dividends, rent, savings, interest, etc.), gifts, such as stocks, bonds or cash, from any source in the last 12 months: Yes ______ No ______ 6. If yes, state: a. The amount of income or gift, or its value: __________________________________ _____________ b. Date received: ____________________ _______________ c. From whom or what received: __________________ __________________ ____________ 7. List all property owned, whether held in your name alone or jointly with anyone else: a. Real estate: _________________________________________________ ____________________ __________________ ___________ b. Property (stocks, bonds, bank accounts, vehicles): __________________________ ______________________ __________________________ ______________________ >>>> 4 c. Name and address of any joint owner, designating which property is jointly owned and name and relationship to joint owner: ________________________________________ ________ 8. If you have a spouse, state: a. Amount of income received: ___________________________ _____________________ b. Source: __________________________________ ______________ c. Frequency income is received: ______________________________ __________________ 9. If you are prisoner, attach Department of Correction certified statement of your income account, together with this affidavit. This statement must contain all account activity for the six-month period immediately preceding the filing of the Complaint, or for the entire period of incarceration, whichever time is less. If the Court determines that you may proceed in forma pauperis, the Court shall issue an order directing the total amount to be paid, and establish a schedule for payment. The schedule must include an initial payment in an amount equal to 20% of the average daily balance of your inmate account over the previous six month period or the entire time that you have been incarcerated, whichever time is less. In each successive month, until the established court costs and filing fees are paid in full, the Court will order you to pay 10% of the average daily balance of the inmate account for the preceding month. 10 Del.C. 8804. 10. If not listed above, state: a. Amount of cash held individually or jointly (whether in a bank or not): ________________________________________________ >>>> 5 b. Bank accounts, listing bank, account number(s), and current balances: __________________________________ _______________ __________________________________ _______________ 11. Itemize debts and regular monthly expenses: ________________________ _____________________ __________ ________________________ __________________ _____________ ________________________ __________________ _____________ 12. List names and addresses of any dependents: _______________________________________ _______________ __________________________________ ____________________ I, ___________________________, swear or affirm that the above information is true and correct and is made under penalty of perjury. Dated: _______________ _________________________________ SIGNATURE Pursuant to Court of Common Pleas Rule 110 (attached), I understand that in the event of a money judgment or recovery in my favor, I will be required to pay any court costs that have been accrued in this action. I further understand that if the Court directs that I pay certain fees and court costs >>>> 6but dismisses my complaint or claim, the Court retains power over me until all costs and fees are paid. SWORN TO AND SUBSCRIBED before me this _________ day of ________________, 20 ____. _________________ _____________ Title * All requests for information must be supplied, if possible. Failure to supply information may result in a denial of your motion to proceed in forma pauperis >>>> 7 IN THE COURT OF COMMON PLEAS FOR THE STATE OF DELAWARE IN AND FOR 1 KENT 1 NEW CASTLE COUNTY 1 SUSSEX COUNTY IN RE: _____________________ Plaintiff Civil Action No: ______________ vs. _____________________ Defendant ORDER TO PROCEED IN FORMA PAUPERIS The Court has reviewed the Petitioners application and, if necessary, has questioned the Petitioner under oath and hereby: __________ Waives all fees and costs __________ Requires $__________ to be paid by ___________ (date) __________ Establishes the following schedule for Payment: If amounts due are not paid by dates ordere d, the action will be dismis sed. IT IS SO ORDERED , this _____ day of ______________, 20____. __________________ ___________ JUDGE >>>> 8 RULE 110 PROCEEDINGS IN FORMA PAUPERIS Upon application of a party to be indigent, th