Fill and Sign the Pursuant to Supreme Court Rules 20 26 and 30 I 6 Declare Form

IN THE SUPREME COURT OF THE STATE OF DELAWARE ____ [1] ___________, ___ [2] ___ Below, Appellant, v. ____ [3] ___________, ___ [4] ___ Below, Appellee. No. ___ [5] ___ MOTION TO PROCEED IN FORMA PAUPERIS 1. Pursuant to Supreme Court Rules 20, 26, and 30, I, ___ [6] ___, declare that I am the appellant in the above-entitled case; that because of my poverty I am unable to make prepayment of fees or costs or to give security therefor; and that I believe I am entitled to relief. 2. I appeal from an order of the ___ [7] ___ Court, entered on the date of ___ [8] ___ in the case of ___ [9] ___ v. ______, No.___ [10] ___. 3. Circle either A or B and complete, as appropriate: A I am presently employed. The name and address of my employer are ___ [11] ___. The total monthly amount of my salary or wages is ___ [12] ___. B I am not employed. My last date of employment was ___ [13] ___. The total amount I last received as salary or wages was ___ [14] ___. -2- 4. Circle "yes" or "no." I have received within the last 12 months money from: a business, profession, or self-employment yes no rent payment, interest, or dividends yes no pensions, annuities, or life insurance payments yes no gifts or inheritances yes no any other source yes no If answer is “yes” to any portion of the above statement, please describe each source of income and the total amount received within the last 12 months: ___ [15] ___. 5. I have $___ [16] ___ in cash and $___ [17] ___ in checking or savings accounts (including funds in prison accounts). 6. I own: real estate yes no bonds or stocks yes no notes yes no cars yes no other valuable property (except ordinary household yes no furnishings and clothes) If answer is “yes” to any portion of the above statement, please describe the item and give its approximate value: ___ [18] ___. 7. Circle either A or B and complete, as appropriate: -3- A I have previously moved to proceed in forma pauperis in the Supreme Court of Delaware. The case number was ___ [19] ___. The request was ___ [20] ___. B I have not previously moved to proceed in forma pauperis in the Supreme Court of Delaware. WHEREFORE, having shown just cause for relief, appellant moves for leave to proceed in forma pauperis. Appellant SWORN AND SUBSCRIBED before me this ________ day of ______, 19____. Notary Public My commission expires _______________, 19____. -4- I hereby certify that the appellant named herein has the sum of $___ [21] ___ on account to the appellant's credit at the institution where the appellant is confined. I further certify that the appellant has the following securities to the appellant's credit according to the institution’s records: ___ [22] ___. Authorized Officer of Institution O R D E R This ________day of __________________, 19____, upon consideration of appellant’s motion for leave to proceed in forma pauperis, it is hereby ORDERED that appellant be GRANTED/DENIED leave to proceed in forma pauperis, limited only to waiver of the docketing deposit required by Supreme Court Rule 20(a). BY THE COURT: Justice -5- Insert : [1] Appellant's name. [2] Appellant's lower court status. [3] Appellee's name. [4] Appellee's lower court status. [5] Supreme Court appeal number, if known. [6] Appellant's name. [7] Lower court. [8] Date of decision on appeal. [9] Lower court case caption. [10] Lower court case number. [11] Name and address of employer. [12] Total monthly amount of salary or wages. [13] Date last employed. [14] Total amount of salary or wages last received. [15] If answer is "yes" to question 4, describe each source of income and the total amount received within the last 12 months. [16] Total amount of cash on hand. -6- [17] Total amount of funds available in checking or savings accounts, including funds in prison accounts. [18] If answer is "yes" to question 6, describe each item and give its approximate value. [19] Case number(s) of any prior Supreme Court appeal in which a request was made to proceed in forma pauperis. [20] Indicate whether the prior request(s) to proceed in forma pauperis was granted or denied. [21] Amount on account at institution. [22] Securities to credit according to institution's records.