Superior-13 (revised January 2019) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT PLAINTIFF/PETITIONER DEFENDANT/RESPONDENTS MOTION TO PROCEED IN FORMA PAUPERIS Plaintiff /Petitioner Case Number Defendant /Respondent Murray Judicial Complex Newport County 45 Washington Square Newport, Rhode Island 02840 - 2913 (401) 841 - 8330 Noel Judicial Complex Kent County 222 Quaker Lane Warwick, Rhode Isl and 02886 - 0107 (401) 822 - 6900 McGrath Judicial Complex Washington County 4800 Tower Hill Road Wakefield, Rhode Island 02879 - 2239 (401) 782 - 412 1 Licht Judicial Complex Providence/Bristol County 250 Benefit Street Providence, Rhode Island 02903 - 2719 (401) 458 - 323 0 Now comes the Plaintiff/Petitioner Defendant/Respondent and prays that this court waive the filing fees, service of process fees, and transcript costs on the grounds that the Plaintiff/Petitioner Defendant/Respondent is presently indigent and as such, has no funds with which to pay these costs. An Affidavit in Support of Motion to Proceed in Forma Pauperis is submitted in support of this motion. /s/ Attorney for the Plaintiff /Petitioner Defendant /Respondent or the Plaintiff /Petitioner Defendant /Respondent Rhode Island Bar Number: Date: Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com Superior-13 (revised January 2019) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT PLAINTIFF/PETITIONER S AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED IN FORMA PAUPERIS Plaintiff /Petitioner Case Number Defendant /Respondent PERSONAL INFORMATION NAME: AGE: ADDRESS: MARITAL STATUS: M S D W CITY: NUMBER OF DEPENDENTS AND AGES TELEPHONE: EMPLOYMENT INFORMATION EMPLOYED: Y N EMPLOYER: HOW LONG: ADDRESS: UNEMPLOYMENT INSURANCE: Y N INCOME: $ per month INCOME: $ per month OTHER INCOME (GOVERNMENT BENEFITS, CHILD SUPPORT, ALIMONY, PENSION, ETC.) INCOME PER MONTH: SOURCE(S): SHELTER COSTS IF OWN HOME: VALUE $ MORTGAGE/LIEN: $ IF RENT: MONTHLY $ IF BOARD, WITH WHOM: $ MONTHLY CONTRIBUTION (IF ANY): $ UTILITIES (MONTHLY): $ GAS: $ ELECTRICITY: $ OIL: $ FOOD (MONTHLY): $ CLOTHING (MONTHLY) $ CHILD SUPPORT PAID (MONTHLY): $ OTHER (SPECIFY): $ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Superior-13 (revised January 2019) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT ASSETS VALUE LIABILITIES AMOUNT MOTER VEHICLE $ LOANS (BANK OR PRIVATE): $ TYPE: COURT OBLIGATIONS (COSTS, YEAR: FINES, RESTITUTION): $ CUSTOMER LOANS/CREDIT CARDS: $ CAR, BOAT, TRUCK, MEDICAL BILLS: $ MOTORCYCLE $ TAXES: $ OTHER (INSURANCE, LEGAL FEES, BANK ACCOUNT BALANCES EDUCATION, ETC.): $ CHECKING: $ SAVINGS: $ REAL PROPERTY: $ OTHER (IRA, CD, TRUSTS, STOCKS, BONDS, ETC.) $ I , attest that the information provided is truthful, complete and accurate to the best of my knowledge. I am aware that any false statement or representation knowingly made shall cause me to be subject to charges of perjury in accordance with the laws of the State of Rhode Island and Providence Plantations. Signature of the Plaintiff/Petitioner or the Defendant/Respondent State of County of On this day of , 20, before me, the undersigned notary public, personally appeared personally known to me or proved to me through satisfactory evidence of identification, which was , to be the person who signed above in my presence, and who swore or affirmed to me that the contents of the document are truthful to the best of his or her knowledge. Notary Public: My commission expires: Notary identification number: Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Superior-13 (revised January 2019) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT Plaintiff /Petitioner Case Number Defendant /Respondent ORDER MOTION IN FORMA PAUPERIS GRANTED: It is hereby ordered that the Plaintiff/Petitioner Defendant/Respondent may file the complaint, petition, or appeal without payment of the filing fee and that the duly authorized officer in accordance with Title 9, Chapter 5 (writs, summons, and process) of the Rhode Island General Laws shall serve without charge to the Plaintiff/Petitioner Defendant/Respondent any and all summonses, complaints or petitions, motions, orders, and all other required documents in this matter without charge. GRANTED: It is hereby ordered that the Plaintiff/Petitioner Defendant/Respondent may order transcripts without charge. DENIED Entered as an Order of the court on . BY ORDER OF: /s/ Clerk ENTER: /s/ Judicial Officer American LegalNet, Inc. www.FormsWorkFlow.com