Del. R. Sup. Ct. Q

As amended through November 14, 2024

Form Q - Disclosure of Corporate Affiliations and Financial Interest [Rule 7]

IN THE SUPREME COURT OF THE

STATE OF DELAWARE

[1]______________________,	:	No. [5] ____________, 20___
[2]____________ Below-	:
Appellant,	:
v.	:
	:
[3]______________________,	:
[4]____________ Below-	:
Appellee.	:

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 [10]_______________________________. The total amount of my salary or wages is [11]$__________ per ____________ [e.g., week or month].

B. I am not employed. My last date of employment was [12]________. The 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	yes	no
rent payment, interest, or dividends	yes	no
pensions, annuities, or insurance payments	yes	no
gifts or inheritances	yes	no
any other source	yes	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:

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

(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:

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) The facts alleged are true and correct;

(iii) 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 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 the appellant has the following securities to the appellant's credit according to the institution=s records:

[22]________________________________________.

_________________________________

Authorized Officer of Institution

[1]______________________,	:	No. [5] ____________, 20___
[2]____________ Below-	:
Appellant,	:
v.	:
	:
[3]______________________,	:
[4]____________ Below-	:
Appellee.	:

O R D E R

This ________day of __________________, ______, 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

Instructions for IFP Motion:

[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] Lower court.

[7] Date of decision on appeal.

[8] Lower court case caption.

[9] Lower court case number.

[10] Name and address of your employer.

[11] Total amount of salary or wages per week, month, or year as indicated.

[12] Date you were last employed.

[13] Name and address of your last employer.

[14] Total amount of salary or wages you last received.

[15] Weekly unemployment compensation, if any.

[16] Spouse's name.

[17] Spouse's total monthly salary or wages.

[18] If any answer is "yes" to question 5, describe each source of income and the total amount received within the last 12 months.

[19] Total amount of cash on hand held by appellant and/or appellant's spouse.

[20] Total amount of funds available in individual or joint checking or savings accounts, including funds in prison accounts.

[21] The amount on account at the institution where the appellant is confined.

[22] Securities to appellant's credit according to institution's records.

Del. R. Sup. Ct. Q