IN THE SUPREME COURT OF THE STATE OF DELAWARE _____________________________, ________________ BelowAppellant, v. _____________________________, ________________ BelowAppellee. § § § No. ______, _______ § [Clerk will insert appeal number] § § § § § § § MOTION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS (1) Pursuant to Supreme Court Rules 20, 26, and 30, I, ________________________ [insert your name], being duly sworn, declare that I am the appellant in the above-captioned case; that because of my financial circumstances I am unable to make prepayment of fees or costs or to give security therefor; and that I believe I am entitled to relief. (2) I appeal from an order of the __________________ [insert name of trial court], entered on the date of ________________________ [insert date of order being appealed], in the case of __________________ v. ___________________ [insert case caption], in Civil/Criminal [circle appropriate designation] Action No. _________________ [insert trial court case number]. (3) You must circle either A or B below and complete the information in the selected paragraph: American LegalNet, Inc. www.FormsWorkFlow.com A. I am presently employed. _____________________________. The name of my employer is My employer’s address is _______________________. My total take home pay per pay period is $______________ per ___________ [e.g., week or month]. B. I am not employed. __________________. My last date of employment was The name and address of my last employer is ____________________________. The total amount I last received as salary or wages was $________________. I presently receive unemployment compensation in the weekly amount of $_____________ [if this does not apply, write “N/A”]. (4) You must circle either “yes” or “no” for each statement below. I have received within the last 12 months money from: a business, profession, or self-employment rent payment, interest, or dividends pensions, annuities, or life insurance payments workers’ compensation or other disability payments gifts or inheritances any other source yes yes yes yes yes yes no no no no no no If you answered Ayes@ to any statement above, please describe each source of income and the total value or amount received within the last 12 months: 2 American LegalNet, Inc. www.FormsWorkFlow.com (5) I have $_________ in cash (not held in an account). I have the following bank accounts (whether individual or joint accounts): Type of Account (6) Account No. Name of Bank/Institution Current Balance You must circle either “yes” or “no” for each statement below, whether title is held in your name alone or jointly held with another person(s). I own: real estate bonds or stocks notes cars other valuable property (except ordinary household furnishings and clothes) yes yes yes yes no no no no yes no If you marked “yes” to any statement above, you must provide further information in the space provided. If you own real estate, please provide the address OR Tax Parcel ID for each parcel of real estate, the current value of the property, and the amount of any mortgages or liens against the property. For other personal property marked “yes” above, please describe the property, provide its current value, and the amount of any liens against the property. 3 American LegalNet, Inc. www.FormsWorkFlow.com Description of Property (7) Current Value Amount of Lien I am/am not married [circle appropriate response]. If you are married, please provide your spouse’s name: _____________________. If your spouse is employed, please provide the name of your spouse’s employer: ___________________________ and your spouse’s total takehome pay per pay period: ___________ per __________. (8) I do/do not have dependents [circle appropriate response]. Please provide the names, ages, and addresses of any dependents: Name Age (9) Address I have the following debts and regular monthly expenses: 4 American LegalNet, Inc. www.FormsWorkFlow.com (10) You must circle either A or B below and complete the information as appropriate. A. I have previously moved to proceed in forma pauperis in the Supreme Court of Delaware. For each case, please provide the case name and number and indicate whether the request was granted or denied. Case Name B. Case Number Granted/Denied I have not previously moved to proceed in forma pauperis in the Supreme Court of Delaware. (11) I am/am not an inmate [circle appropriate response]. If you are an inmate, you must have the Department of Correction fill out the attached certified statement of your inmate account. WHEREFORE, having shown just cause for relief, appellant moves for leave to proceed in forma pauperis. ______________________________ Appellant _____________________________ Street Address _____________________________ City State Zip 5 American LegalNet, Inc. www.FormsWorkFlow.com SWORN AND SUBSCRIBED before me this ________ day of _______________, ______. Commission expires: _____________, ______ ______________________________ Notary Public 6 American LegalNet, Inc. www.FormsWorkFlow.com Department of Correction Certified Statement I hereby certify that the appellant named herein has the sum of $________ on account to the appellant’s credit at the institution where the appellant is confined. I further certify that the appellant has the following securities to the appellant’s credit according to the institution’s records: ______________________________ Authorized Officer of Institution 7 American LegalNet, Inc. www.FormsWorkFlow.com IN THE SUPREME COURT OF DELAWARE _______________________, __________ Below, Appellant, v. _______________________, __________ Below, Appellee. § § § § § § § § § § § No. _____, ______ ORDER This _________ day of ______________, ______, upon consideration of appellant’s motion for leave to proceed in forma pauperis, it is hereby ORDERED that appellant’s motion is GRANTED/DENIED, limited only to waiver of the docketing deposit required by Supreme Court Rule 20(a). BY THE COURT: ______________________________ Justice 8 American LegalNet, Inc. www.FormsWorkFlow.com