Form 198DN (Rev. 12/10) The Family Court of the State of Delaware In and For New Castle Kent Sussex County MOTION AND AFFIDAVIT TO BE FOUND INDIGENT AND REQUEST FOR APPOINTMENT OF AN ATTORNEY IN DEPENDENCY PROCEEDINGS Petitioner Name Respondent Name File Number Street Address Street Address P.O. Box Number P.O. Box Number Case Number City/State/Zip Code City/State/Zip Code Date of Birth Date of Birth If a hearing is scheduled in this matter, will Petitioner need an interpreter? Yes (If yes, specify language Yes (If yes, specify language If a hearing is scheduled in this matter, will Respondent need an interpreter? ) ) No No I am the respondent in the above-captioned case, and I can not afford an attorney. I respectfully request the Court to appoint counsel. I am am not presently employed. Current monthly salary: If not employed, monthly salary from previous job: (Date last employed: ) $ $ If self-employed, average monthly income: $ TOTAL income from employment (a): I receive monthly payments from the following: Pension: Unemployment Compensation: Worker's Compensation or disability payments: Interest or dividends: Other: $ $ $ $ $ $ TOTAL income from monthly payments (b): $ TOTAL from employment and payments (a+b): I make monthly payments from the following: Child Support: Mortgage: Automobile loan: Personal or other loan: Other: $ $ $ $ $ $ TOTAL monthly payments on debts (c): AVAILABLE INCOME (a+b-c) $ $ I have $ In cash and $ In checking and/or savings accounts. 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 198DN (Rev. 12/10) OTHER INCOME AND ASSETS THAT MAY BE CONSIDERED: I have received money from the following sources in the last 12 months: Life Insurance: Other sources: $ $ Gifts or inheritance: $ I own the following, including estimated value: Real Estate: Cars or other vehicles: $ $ Stocks or Bonds: Other Property: $ $ If an attorney does not represent me in this case there is a risk that the procedures used will lead to an erroneous decision because: Reasons why I can not afford an attorney: SWORN TO AND SUBSCRIBED before me this date, Notary Public Movant Do not sign until you are in the presence of a Notary Public. You may wait to sign this form until you appear in Court. You must bring this form with you at your scheduled Court appearance. NOTICE: Intentionally providing false, incomplete or misleading information on this form may result in criminal prosecution. ORDER Having considered the request of the movant, IT IS SO ORDERED, THIS DATE , That the movant is determined to be indigent, and the Court shall appoint counsel to represent him/her. Judge CC: Petitioner Respondent State Agency Petitioner's Attorney Respondent's Attorney Other: File DAG American LegalNet, Inc. www.FormsWorkFlow.com 2 of 3 Form 198DN (Rev. 12/10) AFFIDAVIT OF MAILING I affirm that at true and correct copy of the Motion was placed in the U.S. mail on this date, and sent to the last known address of the other party or attorney, , first class being postage pre-paid. Movant/Attorney/Court Staff SWORN TO AND SUBSCRIBED before me on this date, . Notary Public /Clerk of Court 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com