Form 198DN Rev 12/13 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 Street Address (including Apt) P.O. Box Number City/State/Zip Code Phone Number Interpreter needed? Language D.O.B. Yes No Respondent Name Street Address (including Apt) P.O. Box Number City/State/Zip Code Phone Number Interpreter needed? Language D.O.B. Yes No Petition Number File Number 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 4 American LegalNet, Inc. www.FormsWorkFlow.com Form 198DN Rev 12/13 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. AFFIDAVIT OF MAILING I, the Movant, affirm that a true and correct copy of this Motion was placed in the U.S. Mail on the day of and sent to the other party or attorney at the address listed on the petition, first class postage pre-paid. Movant Sworn to subscribed before me this ______ day of ______________________, _________ Clerk of Court/ Notary Public 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Form 192 Rev 10/10 The Family Court of the State of Delaware In and For New Castle , Petitioner Kent Sussex County v. , Respondent ) ) ) ) ) ) ) ) ) File No.: Petition No.: NOTICE OF MOTION TO: PLEASE TAKE NOTICE that the attached Motion is herewith presented to the Court for consideration. If you are opposed to this motion, you must file a written response with the Court within ten (10) days of the service of this motion. If no response is timely filed, the motion may be decided without further opportunity for you to be heard on the matter. Family Court Rules, Rule 7(b)(2). Date Movant/Attorney Name and address of Movant/Attorney Street Address (including Apt) P.O. Box Number City/State/Zip Code 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Form 193 Rev 5/16 The Family Court of the State of Delaware In and For New Castle Kent Sussex County ) ) ) ) ) ) ) ) ) , Petitioner File No.: Petition No.: In Re: v. , Respondent ORDER Having considered the request of the movant, IT IS SO ORDERED, this date: That , Judge/Commissioner CC: Petitioner Other Respondent Petitioner Attorney Respondent Attorney DAG PD DCSS FC.Appointed.Attorneys@state.de.us 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com