AFFIDAVIT VERSUS Name Of PlaintiffName Of DefendantPETITION TO PROCEED AS AN INDIGENTG.S. 1-110; 7A-228(check one of the four boxes below) Petition To Assert Claims - As a party in the above entitled action, I affirm that I am financially unable to advance the required costs for the prosecution of the claims I have asserted. Therefore, I now petition the Court for an order allowing me to assert my claims as an indigent. I am an inmate in the custody of the Division of Adult Correction and Juvenile Justice. (NOTE TO CLERK: If this block is checked, this Petition must be submitted to a Superior Court Judge for disposition provided on the reverse.) Petition To File Motions - As a party in the above entitled action, I affirm that I am financially unable to advance the required costs to file a notice of hearing on a motion. Therefore, I now petition the Court for an order allowing me to file my motion as an indigent. Petition To Appeal - As the individual appellant in the above entitled small claims action, I affirm that I am financially unable to pay the cost for the appeal of this action from small claims to district court. Therefore, I now petition the Court for an order allowing me to appeal this action to district court as an indigent. Petition To File Expunction Petition - As the petitioner in the above entitled action, I affirm that I am financially unable to advance the required costs to file an expunction petition. Therefore, I now petition the Court for an order allowing me to file my expunction petition as an indigent. (check one or more of the boxes below as applicable) I am presently a recipient of Supplemental Nutrition Assistance Program (SNAP/food stamps). Temporary Assistance for Needy Families (TANF). Supplemental Security Income (SSI). I am represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons, or I am represented by private counsel working on behalf of such a legal services organization. (Attach a letter from your legal services attorney File No. STATE OF NORTH CAROLINA CountyIn The General Court Of Justice District Superior Court Division Name And Address Of Petitioner (type or print)Date Commission ExpiresTitle Of Person Authorized To Administer OathsDateDateSignature Of PetitionerSignature SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME CERTIFICATE OF LEGAL SERVICES/PRO BONO REPRESENTATION I certify that the above named petitioner is represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons or is represented by private counsel working on behalf of or under the auspices of such legal services organization. DateSignature Name And Address (type or print) ORDER Based on the Affidavit appearing above, it is ORDERED that: the petitioner is authorized to assert claims, to appeal, or file notices of hearing or petitions in this action as an indigent. the petition is denied.NOTE TO CLERK: If the petitioner is NOT a recipient of SNAP/food stamps, TANF, SSI or is NOT represented by legal services or a private attorney on behalf of legal services, you may ask for additional financial information to determine whether the petitioner is unable to pay the costs. SignatureDate Assistant CSC Clerk Of Superior Court Judge Magistrate (for appeal only)SEAL (Over) American LegalNet, Inc. www.FormsWorkFlow.com ORDER - DACJJ INMATES CERTIFICATION and Juvenile Justice and that the complaint is not frivolous. is frivolous.It is ORDERED that the petitioner is authorized to sue in this action as an indigent. the petitioner is not authorized to sue as an indigent. the action is dismissed.I certify that this Petition has been served on the party named by depositing a copy in a post-paid properly addressed envelope in a post DateName Of Superior Court Judge (type or print)Signature Of Superior Court Judge DateSignature Deputy CSC Assistant CSC Clerk Of Superior CourtNOTE: G.S. 1-110(b) provides: 223The clerk of superior court shall serve a copy of the order of dismissal upon the prison inmate.224 AOC-G-106, Side Two, Rev. 2/18 American LegalNet, Inc. www.FormsWorkFlow.com