Fill and Sign the All Requests for Information Must Be Supplied If Possible

Form 257P Rev 2/17 1 of 6 Family Court For the State of Delaware AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS http://courts.delaware.gov/family/ Form 257P Rev 2/17 2 of 6 PROCEEDINGS IN FORMA PAUPERIS  Please complete all portions of the attached applicationAll requests for information must be supplied, if possible. Failure to supply information may result in a denial of your Application to Proceed In Forma Pauperis. Approval of this application will result in the waiver of fees for filing and notice/publication only. Form 257P Rev 2/17 3 of 6 The Family Court of the State of Delaware In and For New Castle Kent Sussex County AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS Petitioner v. Respondent Name Name File Number Street Address (including Apt) Street Address (including Apt) P.O. Box Number P.O. Box Number Petition Number City/State/ Zip Code City/State/Zip Code Attorney Name A Attorney Name I, , being first duly sworn, depose and say that I amthe Petitioner Respondent in the matter of .In support of my application to proceed without paying Court fees and costs, or give security, I 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. In support of that statement, I supply the following information: 1. Are you presently employed? Yes No (If your answer is no, please skip to question 3)2. If Yes, state:a. The name and address of your employer: b.State how often you are paid: c.State the amount of your take home pay per pay period: Form 257P Rev 2/17 4 of 6 * If employed, you must attach a recent pay-stub or other documentation of income.3. If you are not employed, state:a.Name and address of last employer: b.Location and date of last employment: 4. If you are not employed, please state the reason why: 5. If you are not employed, please list any government benefits that you currently receive (SSDI, food stamps, TANF, etc.): 6. 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 the last 12 months: Yes No 7. If yes, state:Amount of income or value of gift Date Received From Whom Received 8. List all property owned, whether held in your name alone or jointly with anyone else: a.Real estate: b. Property (stocks, bonds, bank accounts, vehicles): Type of Benefit (SSDI, TANF, etc.) Monthly Amount Received Form 257P Rev 2/17 5 of 6 c. Name and address of any joint owner, designating which property is jointly owned and name and relationship to joint owner: 9. If you have a spouse, state:a.Amount of income received: b.Source: c.Frequency income is received: 10. Itemize debts and regular monthly expenses: 11. List names, ages and addresses of any dependents:NameAgeAddress I, swear or affirm that the above information is true andcorrect and is made under penalty of perjury. DATE SIGNATURE Sworn to subscribed before me this day of , Clerk of Court/ Notary PublicDate Debt/Expense Monthly Amount Form 259Rev 2/17 6 of 6 The Family Court of the State of Delaware In and For New Castle Kent Sussex County IN RE: Petitioner, File Number: VS. Petition Number: Respondent ORDER ON APPLICATION TO PROCEED IN FORMA PAUPERIS The Court has reviewed the Petitioner’s application and, if necessary, has questioned the Petitioner under oath. Petitioner’s application is hereby: Granted. The Court waives all fees and costs associated with the filing and notice of this action. This does not include waiver of transcript fees. This Order also does not include a waiver of publication costs. Granted in part. Denied. Petitioner must pay all fees and costs associated with the filing and notice of this action. Please remit payment to the cashier’s office. If the above provisions are not completed within 30 days of the date of this Order, the underlying petition is dismissed pursuant to this Order. IT IS SO ORDERED, thisCCCCday of ,CCCC. PAYMENT IS DUE ON OR BEFORE cc: PetitionerRemit payment to: Cashier’s Office, 500 N. King Street, Wilmington, DE 19801 400 Court Street, Dover, DE 1990 22 The Circle, Georgetown, DE 19947Date mailed: Judge/Commissioner