Motion And Affidavit To Proceed In Forma Pauperis Motion And Affidavit To Proceed In Forma Pauperis - Delaware

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Motion And Affidavit To Proceed In Forma Pauperis Motion And Affidavit To Proceed In Forma Pauperis - Delaware Powered By Docstoc
					      IN THE SUPREME COURT OF THE STATE OF DELAWARE

_____________________________,            §
                                          §
       ________________ Below-            § No. ______, _______
       Appellant,                         § [Clerk will insert appeal number]
                                          §
       v.                                 §
                                          §
_____________________________,            §
                                          §
       ________________ Below-            §
       Appellee.                          §

     MOTION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS

       (1)     Pursuant to Supreme Court Rules 20, 26, and 30, I,

________________________ [insert your name], being duly sworn, declare

that I am the appellant in the above-captioned case; that because of my

financial circumstances 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 __________________ [insert name

of trial court], entered on the date of ________________________ [insert date

of   order   being   appealed],   in the case of __________________ v.

___________________ [insert case caption], in Civil/Criminal [circle appropriate

designation] Action No. _________________ [insert trial court case number].

       (3)     You must circle either A or B below and complete the

information in the selected paragraph:



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       A.      I am presently employed.      The name of my employer is

_____________________________.               My    employer’s        address            is

_______________________. My total take home pay per pay period is

$______________ per ___________ [e.g., week or month].

       B.      I am not employed.        My last date of employment was

__________________.           The name and address of my last employer is

____________________________.           The total amount I last received as

salary or wages was $________________.                  I presently receive

unemployment compensation in the weekly amount of $_____________ [if

this does not apply, write “N/A”].

       (4)     You must circle either “yes” or “no” for each statement below.

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
       workers’ compensation or other disability payments           yes       no
       gifts or inheritances                                        yes       no
       any other source                                             yes       no

If you answered Ayes@ to any statement above, please describe each source of

income and the total value or amount received within the last 12 months:




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      (5)    I have $_________ in cash (not held in an account). I have the

following bank accounts (whether individual or joint accounts):

Type of Account    Account No.   Name of Bank/Institution    Current Balance




      (6)    You must circle either “yes” or “no” for each statement below,

whether title is held in your name alone or jointly held with another

person(s).

I own:

      real estate                                                 yes       no
      bonds or stocks                                             yes       no
      notes                                                       yes       no
      cars                                                        yes       no
      other valuable property (except ordinary household
             furnishings and clothes)                             yes no

If you marked “yes” to any statement above, you must provide further

information in the space provided. If you own real estate, please provide the

address OR Tax Parcel ID for each parcel of real estate, the current value of

the property, and the amount of any mortgages or liens against the property.

For other personal property marked “yes” above, please describe the

property, provide its current value, and the amount of any liens against the

property.
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Description of Property                       Current Value         Amount of Lien




       (7)    I am/am not married [circle appropriate response]. If you are

married, please provide your spouse’s name: _____________________. If

your spouse is employed, please provide the name of your spouse’s

employer: ___________________________ and your spouse’s total take-

home pay per pay period: ___________ per __________.

       (8)    I do/do not have dependents [circle appropriate response]. Please

provide the names, ages, and addresses of any dependents:

Name                       Age                                Address




       (9)    I have the following debts and regular monthly expenses:




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      (10) You must circle either A or B below and complete the

information as appropriate.

      A.    I have previously moved to proceed in forma pauperis in the

Supreme Court of Delaware. For each case, please provide the case name

and number and indicate whether the request was granted or denied.

Case Name                             Case Number              Granted/Denied




      B.    I have not previously moved to proceed in forma pauperis in the

Supreme Court of Delaware.

      (11) I am/am not an inmate [circle appropriate response]. If you are an

inmate, you must have the Department of Correction fill out the attached

certified statement of your inmate account.

      WHEREFORE, having shown just cause for relief, appellant moves

for leave to proceed in forma pauperis.


                                      ______________________________
                                      Appellant

                                      _____________________________
                                      Street Address

                                      _____________________________
                                      City           State      Zip
                                      5


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     SWORN AND SUBSCRIBED before me this ________ day of
_______________, ______.

Commission expires:        ______________________________
_____________, ______           Notary Public




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                Department of Correction Certified Statement

      I hereby certify that the appellant named herein has the sum of

$________ 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:




                                        ______________________________
                                        Authorized Officer of Institution




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              IN THE SUPREME COURT OF DELAWARE


_______________________,             §
                                     §
      __________ Below,              §
      Appellant,                     §
                                     §
v.                                   §           No.    _____, ______
                                     §
_______________________,             §
                                     §
      __________ Below,              §
      Appellee.                      §




                                ORDER

      This _________ day of ______________, ______, upon consideration

of appellant’s motion for leave to proceed in forma pauperis, it is hereby

ORDERED that appellant’s motion is GRANTED/DENIED, limited only to

waiver of the docketing deposit required by Supreme Court Rule 20(a).

                                     BY THE COURT:



                                     ______________________________
                                     Justice




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Description: Motion And Affidavit To Proceed In Forma Pauperis Form. This is a Delaware form and can be use in Supreme Court Statewide.