IN THE JUSTICE OF THE PEACE COURT OF THE STATE OF DELAWARE, IN AND FOR ___________________COUNTY COURT NO.__________ IN RE: __________________________ Last name(s) of Plaintiffs CIVIL ACTION NO._______________________ __________________________ Last name(s) of Defendants APPLICATION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS I, ______________________________________ do under the penalty of perjur y declare the following in support of this petition to proceed in the above matter without (check one) ( ) paying some fees or ( ) without posting security for an appeal. INCOME Fill in the source and amount of any income that you or your spouse has received in the past 12 months. You must include all income you or your spouse has received fro m any source, including employment income and earnings from a business, interest, dividends, ren t, gifts or inheritances. (Your spouses income should not be included if you are living separately and not sharing expenses. If you are incarcerated, your spouses income should be included if you were liv ing together before your incarceration and are still married.) TOTAL INCOME SELF SPOUSE SOURCE AMOUNT SOURCE AMOUNT ASSETS Fill in the type and value of assets that you own either individually or jointly with someone else. You must list all assets including, but not limited to, all real and per sonal property, all cash, bank accounts, stocks or bonds cars, or other valuable property. However, you do not n eed to list ordinary household furnishings and clothes. DESCRIPTION OF ASSET VALUE Cash Bank Accounts Stocks or Bonds Automobile Real Estate (other than family home) Other Other J.P. Civ. Form 49 (Rev. 6/15/00) American LegalNet, Inc. www.USCourtForms.com>>>> 2DEBTS AND MONTHLY EXPENSES List all debts and monthly expenses. DESCRIPTION OF DEBTS/MONTHLY EXPENSES AMOUNT DEPENDENTS NAME AND ADDRESS AGE RELATIONSHIP TO YOU IF YOU ARE INCARCERATED, ATTACH DEPARTMENT OF CORRECTION CERTIFIED STATEMENT OF YOUR INMATE ACCOUNT. INJUNCTION FROM FILING CLAIMS I have/have not (circle one) previously been enjoined by a Delaware Court from filing future claims without leave of court for abusing the judicial process by filing frivol ous or malicious litigation. I understand that the failure to supply information requested on this form may result in denial o f my motion to proceed in forma pauperis. I also understand that if the Court directs that I pay certain fees and court costs but dismisses my complaint or claim, the Court keeps power o ver me until all costs and fees are paid. I swear or affirm, under penalty of perjury, that the above information is true and correct. _________________________________________ (signature) SWORN TO AND SUBSCRIBED before me this ______ day of ____________, 20___. ___________________________________(SEAL) Notary Public/Justice of the Peace J.P. Civ. Form 49 (Rev. 6/15/00) American LegalNet, Inc. www.USCourtForms.com>>>> 3 IN THE JUSTICE OF THE PEACE COURT OF THE STATE OF DELAWARE, IN AND FOR ___________________COUNTY COURT NO.__________ IN RE: __________________________ Last name(s) of Plaintiffs CIVIL ACTION NO._______________________ __________________________ Last name(s) of Defendants ORDER The Court has reviewed the above application and, if necessary, has ques tioned the petitioner under oath and hereby: Check if applicable: _______ waives all fees and costs _______ requires $___________ (amount) to be paid by ________________ . (date) _______ establishes the following schedule for payment: If amounts due are not paid by dates ordered, the action will be dismissed. IT IS SO ORDERED, this _____ day of _________________, 20___. ________________________________ Justice of the Peace J.P. Civ. Form 49 (Rev. 6/15/00) American LegalNet, Inc. www.USCourtForms.com