IN THE SUPERIOR COURT OF THE STATE OF DELAWARE COUNTY: New Castle Kent Sussex Plaintiff/Petition/Appellant, v. Defendant/Respondent/Appellee. , , : : : : C.A. No. : : : : AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS I, , being first duly sworn, depose and say that I am the in the above-captioned case; in support of my motion to proceed without paying Court fees and costs, or give security therefor, 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 therefor. In support of that statement, I supply the following information: 1. Nature of claim or defense is: All requests for information must be supplied, if possible. Failure to supply information may result in denial of you motion to proceed In Forma Pauperis. Page | 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. Presently employed? Yes 3. If "Yes", state: (a) Name and address of employer: No (b) How often paid: (c) Take home pay per pay period: 4. If "No", state: (a) Name and address of last employer: (b) 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 twelve months. Yes 6. If "Yes", state: (a) Amount of income or gift, or its value: No (b) When received: All requests for information must be supplied, if possible. Failure to supply information may result in denial of you motion to proceed In Forma Pauperis. Page | 2 American LegalNet, Inc. www.FormsWorkFlow.com (c) From whom or what received: (d) Whether regular or one time: 7. List all property owned, whether held in your name alone or jointly with anyone else: (a) Real estate: (b) Personal property (stocks, bonds, bank accounts, vehicles): (c) Name and address of and relationship to any joint owner, designating which property is jointly owned and name of joint owner: 8. If you have a spouse, state: (a) Amount of any income received: (b) Source (c) Frequency income is received: 9. If a prisoner, attach Department of Correction certified statement of your inmate account. The summary of your inmate account shall contain all account activity for the 6-month period immediately preceding the filing of the complaint, or for the entire time you have been incarcerated, whichever time is less. All requests for information must be supplied, if possible. Failure to supply information may result in denial of you motion to proceed In Forma Pauperis. Page | 3 American LegalNet, Inc. www.FormsWorkFlow.com 10. If a prisoner, provide the following requested information. (a) At any time while incarcerated or detained at any facility, have you previously brought an action or an appeal in a federal court or in any court of this State? (b) If the answer to (a) was yes, identify the court(s) and provide the civil action(s) or appeal number(s) for each case. (c) If the answer to (a) above was yes, state the outcome of each action or appeal. 11. If you are a prisoner and your complaint relates to a condition of confinement, you must have fully exhausted all administrative remedies available through the institutional grievance procedure. If you have not fully exhausted your administrative remedies, do not file the complaint in this matter or the motion to proceed in forma pauperis. If this condition applies to you, state whether you have exhausted all administrative remedies. If you have fully exhausted all administrative remedies, attach copies of all decisions in the administrative process. 12. If not listed above, state: (a) Amount of any cash held (whether or not in a bank) (b) Bank accounts, listing bank, account number(s) and current balance(s). All requests for information must be supplied, if possible. Failure to supply information may result in denial of you motion to proceed In Forma Pauperis. Page | 4 American LegalNet, Inc. www.FormsWorkFlow.com 13. Itemize debts and regular monthly expenses: 14. List names and address of any dependents: I, , swear or affirm that the above-information is true and correct and is made under penalty of perjury. Signature DATED: I understand that if the Court directs that I pay certain fees and court costs but dismisses my complaint or claim, the Court keeps power over me until all costs and fees are paid. SWORN TO AND SUBSCRIBED before me this day of , . Title Revised 03/2016 All requests for information must be supplied, if possible. Failure to supply information may result in denial of you motion to proceed In Forma Pauperis. Page | 5 American LegalNet, Inc. www.FormsWorkFlow.com