Form 257 Rev 8/18 1 of 3 The Family Court of the State of Delaware In and For New Castle Kent Sussex County AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS Petitioner v. Respondent Name Name File Number Street Address (including Apt) Street Address (including Apt) P.O. Box Number P.O. Box Number Petition Number City /S tate / Zip Code City / State / Zip Code Attorney Name Attorney Name I, , being first duly sworn, depose and say that I am the Petitioner Respondent in the matter of . In support of my application 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: 1. Are you presently employed? Yes No (If your answer is no, please skip to question 3 ) 2. 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: American LegalNet, Inc. www.FormsWorkFlow.com Form 257 Rev 8/18 2 of 3 * If employed, you must attach a recent pay-stub or other documentation of income. 3 . If you are not employed, state: a. Name and address of last employer: b. Location and date of last employment: 4. If you are not employed, please state the reason why: 5. If you are not employed, please list any government benefits that you currently receive (SSDI, food stamps, TANF, etc.): 6. 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 the last 12 months: Yes No 7. If yes, state: Amount of income or value of gift Date Received From Whom Received 8. 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): Type of Benefit (SSDI, TANF, etc.) Monthly Amount Received American LegalNet, Inc. www.FormsWorkFlow.com Form 257 Rev 8/18 3 of 3 c. Name and address of any joint owner, designating which property is jointly owned and name and relationship to joint owner: 9. If you have a spouse, state: a. Amount of income received: b. Source: c. Frequency income is received: 10. Itemize debts and regular monthly expenses: 11. List names, ages and addresses of any dependents: Name Age Address I, swear or affirm that the above information is true and correct and is made under penalty of perjury. DATE SIGNATURE PRINT NAME Sworn to subscribed before me this day of , Clerk of Court/ Notary Public Date Debt/Expense Monthly Amount American LegalNet, Inc. www.FormsWorkFlow.com