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Form Q Motion And Affidavit To Proceed In Forma Pauperis Q - Delaware
| Form Q Motion And Affidavit To Proceed In Forma Pauperis Form. This is a Delaware form and can be used in Supreme Court Statewide . |
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SupremeCourtOfficialFormQ IN THE SUPREME COURT OF THE STATE OF DELAWARE [1]______________________, [2]____________ BelowAppellant, v. [3]______________________, [4]____________ BelowAppellee. § § No. [5] _______, 20___ § § § § § § § § § Motion and Affidavit to Proceed In Forma Pauperis (1) Pursuant to Supreme Court Rule 20(h) and 10 Del. C. §§ 8802-04, I, [1]________________________, swear or affirm that the information contained in this motion and affidavit is true and correct and made under penalty of perjury. I declare that I am the appellant in the above-captioned case and that because of my poverty I am unable to make prepayment of fees or costs or to give security therefore. I believe that I am entitled to relief. (2) I appeal from an order of the [6]__________________ Court, entered on the date of [7]________________________ in the case of [8]___________ v. ______________, No. [9]_________________________. (3) You must circle either A or B below and complete the information in the selected paragraph: A. I am presently employed. The name and address of my employer are The total amount of my salary or [10]_______________________________. wages is [11]$__________ per ____________ [e.g., week or month]. B. The I am not employed. My last date of employment was [12]________. name and address of my last employer is [13]__________________________________. The total amount I last received as salary or wages was [14]$____________. I presently receive unemployment compensation in the weekly amount of [15]$__________________. [If this does not apply, write "N/A."] (4) I am/am not married. [Circle appropriate response.] If you are married, please provide your spouse's name: [16]______________________________. My spouse is/is not [Circle appropriate response.] employed. My spouse's total salary or wages is [17]$________________ per ____________. (5) 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 rent payment, interest, or dividends pensions, annuities, or insurance payments gifts or inheritances any other source yes yes yes yes yes no no no no no If the 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: 2 [18]__________________________________________________________. (6) I, and/or my spouse, have [19]$___________ in cash and [20]$____________ in either individual or joint checking or savings accounts (including funds in prison accounts). The accounts in which I and/or my spouse hold money are: Type of Account Account No. Name of Bank/Institution Acct. Balance (7) You must circle either "yes" or "no" for each statement below, whether title is held in your or your spouse's name alone or jointly held by either one of you with another person(s). I, or my spouse, own individually or jointly: real estate bonds or stocks notes cars other valuable property (except ordinary household furnishings and clothes) yes yes yes yes yes no no no no no If the answer is "yes" to any statement above, you must provide further information in the space provided. If you own real estate, please provide the 3 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, its approximate current value, and the amount of any liens against the property. Description of Property Current Value Amount of Lien (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: 4 (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) You must circle either A or B below and complete the information, as appropriate: A. I have never been found by any court to have abused the judicial process by filing frivolous or malicious litigation. B. I previously have been found by a court in Delaware to have filed factually frivolous, legally frivolous, or malicious litigation and have been enjoined from filing future claims without leave of court. For each case, please provide the case name, the case number, and the court issuing the injunction: 5 Case Name Case Number Court (12) If you circled B in Question 11, then you are required to make the following certifications pursuant to 10 Del. C. § 8803(e): I hereby certify that: (i) The claims I seek to raise in the current matter have never been raised or disposed of before in any court; (ii) (iii) The facts alleged are true and correct; I have made a diligent and good faith effort to determine what relevant case law controls the legal issues I seek to raise; (iv) I have no reason to believe that the claims are foreclosed by controlling law; and (v) I understand that this affidavit is made under penalty of perjury. (13) I am/am not an inmate [Circle the appropriate response]. If you are an inmate, you must have the Department of Correction fill out the attached certified statement of your inmate account. (14) I understand that, if I am permitted to proceed in forma pauperis in this matter and the Court later dismisses this action or otherwise enters a judgment against me, then the Court may require me to pay all costs and fees associated with 6 this action and, if so ordered, shall retain jurisdiction over me until the costs and fees are paid. 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 ______, _________. _______________________________ Notary Public My commission expires _______________, 20____. The following section must be completed if the appellant is incarcerated. 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 t
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