Fill and Sign the Application Forma Pauperis

IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE IN AND FOR Please select a county In the Matter of: C.A.#       OR C.M.#             APPLICATION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS Under penalty of perjury, I       declare that all of the following information is true and correct in support of this application to proceed in the above-captioned matter without paying Court fees and costs, or give security therefore: 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 therefore. In support of that statement, I supply the following information: 1. Are you employed? YES NO Self-employed IF "YES": a. Name and address of employer:                   b. How often paid:       c. Take home pay per pay period:       IF "NO" a. Name and address of last employer:                   b. Date of last employment:       All requests for information must be supplied, if possible. Failure to supply information may result in denial of your application to proceed in forma pauperis .1 c. Take home pay per pay period:       2. List ALL income you have received from any source within the last 12 months and identify the source if it is not listed on the table below. (Attach additional pages if necessary.) SOURCE OF INCOME AMOUNT WHEN RECEIVED HOW OFTEN RECEIVED (one time or regular) Business, profession or self-employment                   Rent payments                   Interest                   Dividends from stocks or bonds                   Retirement or annuity payments (i.e. disability, social security etc.)                   Bank account interest                   Gifts                   Other:                         3. If you have a spouse, list ALL income YOUR SPOUSE has received from any source within the last 12 months and identify the source if it is not listed on the table below. (Attach additional pages if necessary.) SOURCE OF INCOME AMOUNT WHEN RECEIVED HOW OFTEN RECEIVED (one time or regular) Business, profession or self-employment                   Rent payments                   Interest                   Dividends from stocks or bonds                   Retirement or annuity payments (i.e. disability, social security etc.)                   Bank account interest                   Gifts                   Other:                         All requests for information must be supplied, if possible. Failure to supply information may result in denial of your application to proceed in forma pauperis .2 4. List ALL property owned, whether held in your name alone or jointly with anyone else. (Attach additional pages if necessary.) PROPERTY VALUE IF OWNED JOINTLY NAME AND ADDRESS OF JOINT OWNER Cash             Bank Accounts             Stocks or Bonds             Automobile and other vehicles             Real Estate             Other valuable property (except ordinary household furnishings and clothes)             Other:                   5. List ALL debts and monthly expenses. (Attach additional pages if necessary.) DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS TOTAL DEBT MONTHLY PAYMENT                                                                                                                                                                   6. List names and addresses of all dependents, persons you actually support, (children or other) and their relationship to you. (Attach additional pages if necessary.) DEPENDENTS NAME AND ADDRESS AGE RELATIONSHIP TO YOU                                                                         All requests for information must be supplied, if possible. Failure to supply information may result in denial of your application to proceed in forma pauperis .3 7. ONLY IF YOU ARE INCARCERATED, complete all parts of this question. If you are NOT incarcerated, do not complete this question. a. ATTACH a Department of Correction certified statement of your inmate account that includes all account activity for the 6-month period immediately before the filing of this application, OR for the entire time you have been incarcerated, whichever time is less. b. 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 in this State? YES NO If "YES” complete the table below: NAME OF COURT CIVIL ACTION OR APPEAL NUMBER OUTCOME                                                       d. If your complaint relates to a condition of confinement, you MUST have fully exhausted all administrative remedies available through the institutional grievance procedure. Have you exhausted all administrative remedies? YES NO If " YES " ATTACH copies of all decisions in the administrative process. If " NO " do not file the complaint in this matter or this application. 8. Have you previously filed an application to proceed in forma pauperis in the Court of Chancery? YES NO If " YES " state the case number(s) and outcome(s) of your previous application:       All requests for information must be supplied, if possible. Failure to supply information may result in denial of your application to proceed in forma pauperis .4 I, Error: Reference source not found , swear or affirm that all of the above information is true and correct and is made under penalty of perjury. SIGNATURE: DATE: I understand that if the Court directs that I pay certain fees and court costs but dismisses my complaint or claim, the Court keeps the power over me until all costs and fees are paid. SWORN TO AND SUBSCRIBED before me on this date: Notary Public or Clerk of the Court IT IS SO ORDERED this _____day of________________, 20___, The following Court Costs are hereby waived: Filing Fees Attorney Ad Litem Fees Court Costs (Vice) Chancellor/Master All requests for information must be supplied, if possible. Failure to supply information may result in denial of your application to proceed in forma pauperis .5