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Petition To Sue Appeal As An Indigent G-106 - North Carolina

Petition To Sue Appeal As An Indigent Form. This is a North Carolina form and can be used in General Statewide .
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STATE OF NORTH CAROLINA County Name Of Plaintiff File No. In The General Court Of Justice Superior Court Division District VERSUS Name Of Defendant PETITION TO SUE/APPEAL/FILE MOTIONS AS AN INDIGENT G.S. 1-110; 7A-228 AFFIDAVIT (check one of the three boxes below) Petition To Sue - As a plaintiff in the above entitled action, I affirm that I am financially unable to advance the required costs for the prosecution of this action. Therefore, I now petition the Court for an order allowing me to bring suit in this action as an indigent. I am an inmate in the custody of the Division of Adult Correction. (Note To Clerk: If this block is checked, this Petition must be submitted to a Superior Court Judge for disposition provided on the reverse.) Petition To File Motions - As a defendant debtor in the above entitled action, I affirm that I am financially unable to advance the required costs to file a motion. Therefore, I now petition the Court for an order allowing me to file my motion as an indigent. Petition To Appeal - As the individual appellant in the above entitled small claims action, I affirm that I am financially unable to pay the cost for the appeal of this action from small claims to district court. Therefore, I now petition the Court for an order allowing me to appeal this action to district court as an indigent. (check one or more of the boxes below as applicable) I am presently a recipient of food stamps. Aid to Families With Dependent Children (AFDC). Supplemental Security Income (SSI). I am represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons, or I am represented by private counsel working on behalf of such a legal services organization. (Attach a letter from your legal services attorney or have your attorney sign the certificate below.) Although I am not a recipient of food stamps, AFDC, or SSI, nor am I represented by legal services, I am financially unable to advance the costs of filing this action or appeal. SWORN AND SUBSCRIBED TO BEFORE ME Date Date Signature Signature Of Petitioner Title Of Person Authorized To Administer Oaths Name And Address Of Petitioner (Type Or Print) Date Commission Expires SEAL CERTIFICATE OF LEGAL SERVICES/PRO BONO REPRESENTATION I certify that the above named petitioner is represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons or is represented by private counsel working on behalf of or under the auspices of such legal services organization. Date Signature Name And Address (Type Or Print) ORDER Based on the Affidavit appearing above, it is ORDERED that: the petitioner is authorized to bring suit, to appeal, or file motions in this action as an indigent. the petition is denied. Date Signature Assistant CSC Judge Clerk Of Superior Court Magistrate (for appeal only) NOTE TO CLERK: If the petitioner is NOT a recipient of food stamps, AFDC, SSI or is NOT represented by legal services or a private attorney on behalf of legal services, you may ask for additional financial information to determine whether the petitioner is unable to pay the costs. AOC-G-106, Rev. 1/12 2012 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com ORDER - DAC INMATES The undersigned superior court judge of this district finds that the petitioner is an inmate in the custody of the Division of Adult Correction and that the complaint is not frivolous. is frivolous. It is ORDERED that the petitioner is authorized to sue in this action as an indigent. the petitioner is not authorized to sue as an indigent. the action is dismissed. Date Name Of Superior Court Judge (Type Or Print) Signature Of Superior Court Judge CERTIFICATION I certify that this Petition has been served on the party named by depositing a copy in a post-paid properly addressed envelope in a post office or official depository under the exclusive care and custody of the United States Postal Service. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court NOTE: G.S. 1-110(b) provides: "The Clerk of Superior Court shall serve a copy of the order of dismissal upon the prison inmate." AOC-G-106, Side Two, Rev. 1/12 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com
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