Asset Recovery Handbook

Application and Affidavit to Proceed In Forma Pauperis

IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE

IN AND FOR

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:

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.)

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.)

4. List ALL property owned, whether held in your name alone or jointly with anyone else. (Attach additional pages if necessary.)

5. List ALL debts and monthly expenses. (Attach additional pages if necessary.)

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.)

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.

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:

d. Have you exhausted all administrative remedies? YES NO

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:

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