Fill and Sign the Custody Modification Instruction Packet Delaware Courts Form

Form 198DNRev 2/18 1 of 3 The Family Court of the State of Delaware In and For New Castle County Kent County Sussex County MOTION AND AFFIDAVIT TO BE FOUND INDIGENT AND REQUEST FOR APPOINTMENT OF AN ATTORNEY IN DEPENDENCY PROCEEDINGS Petitioner Respondent I am the respondent in the above-captioned case, and I can not afford an attorney. I respectfully request the Court to appoint counsel.I am am not presently employed. Current monthly salary: $ If not employed, monthly salary from previous job: $ (Date last employed: )If self-employed, average monthly income: $ TOTAL income from employment (a): $ I receive monthly payments from the following:Pension: $ Unemployment Compensation: $ Worker’s Compensation or disability payments: $ Interest or dividends: $ Other: $ TOTAL income from monthly payments (b):$ TOTAL from employment and payments (a+b): $ I make monthly payments from the following:Child Support: $ Mortgage: $ Automobile loan: $ Personal or other loan: $ Other: $ TOTAL monthly payments on debts (c):$ AVAILABLE INCOME (a+b-c)$ I have $ In cash and $ In checking and/or savings accounts. NameName File Number Street Address (including Apt) Street Address (including Apt) P.O. Box NumberP.O. Box Number City/State/Zip CodeCity/State/Zip Code Petition Number Phone Number D.O.B.Phone Number D.O.B. Interpreter needed? Yes No Interpreter needed? Yes NoLanguage Language Form 198DNRev 2/18 2 of 3 OTHER INCOME AND ASSETS THAT MAY BE CONSIDERED:I have received money from the following sources in the last 12 months:Life Insurance: $ Gifts or inheritance: $ Other sources: $ I own the following, including estimated value:Real Estate:$ Stocks or Bonds: $ Cars or other vehicles:$ Other Property: $ If an attorney does not represent me in this case there is a risk that the procedures used will lead to an erroneous decision because: Reasons why I can not afford an attorney: SWORN TO AND SUBSCRIBED before me this date, Notary Public Movant Do not sign until you are in the presence of a Notary Public. You may wait to sign this form until you appear in Court. You must bring this form with you at your scheduled Court appearance.NOTICE: Intentionally providing false, incomplete or misleading information on this form may result in criminal prosecution. AFFIDAVIT OF MAILING I, the Movant, affirm that a true and correct copy of this Motion was placed in the U.S. Mail on the day of and sent to the other party or attorney at the address listed on the petition, first class postage pre-paid. Movant Sworn to subscribed before me this ______ day of ______________________, _________ Clerk of Court/ Notary Public ORDER Having considered the request of the movant, ,IT IS SO ORDERED, this date: That the movant is determined to be indigent, and the Court shall appoint counsel to represent him/her. is determined to not be indigent. Judge/Commissioner CC: Petitioner Respondent Petitioner Attorney Respondent Attorney DAG Appointed Counsel Fiscal Services FC.Appointed.Attorneys@state.de.us Other: Form 193Rev 5/16 3 of 3 The Family Court of the State of Delaware In and For New Castle Kent Sussex County , Petitioner File No.: v. Petition No.: , Respondent ))))))))) NOTICE OF MOTION TO: PLEASE TAKE NOTICE that the attached Motion is herewith presented to the Court for consideration. If you are opposed to this motion, you must file a written response with the Court within ten (10) days of the service of this motion. If no response is timely filed, the motion may be decided without further opportunity for you to be heard on the matter. Family Court Rules, Rule 7(b)(2). Movant/Attorney Name and address of Movant/Attorney Street Address (including Apt) P.O. Box Number City/State/Zip Code Date