STATE OF SOUTH CAROLINA, COUNTY OF ___________________
_________________________________ Plaintiff vs. _________________________________ Defendant.
) ) ) ) ) ) ) ) ) ) )
IN THE _________________________ COURT ____________ JUDICIAL CIRCUIT MOTION AND AFFIDAVIT TO PROCEED IN FORMA PAUPERIS
FILE NO.
_________________________________
I, __________________________________________, being duly sworn, state that I am the Plaintiff and that I do not have the funds available to pay the costs of filing and service in the present matter. I hereby request that the complaint be filed and service made without costs. Sworn to and Subscribed before me this ____ day of ________________, 2______. ) ) ) ) Notary Public for South Carolina ) ) My Commission expires _________________ )
Signature of Plaintiff or Person Filing Complaint on Behalf of Plaintiff
ORDER Leave Dated: (granted) / (denied) to proceed in forma pauperis. , 2_____
JUDGE/CLERK OF COURT
____________________
______________________ ,
South Carolina
NOTICE TO PLAINTIFF:
The Court may assess costs against either party at hearing.
SCCA/741 (Amended 05/2008)