IN THE SUPERIOR COURT OF ______________ COUNTY

STATE OF GEORGIA

_____________________________, ]

]

Petitioner ]

]

V. ] Civil Action File No. _____________

]

_____________________________, ]

]

Respondent ]

PAUPER’S AFFIDAVIT

Personally appeared before the undersigned officer, duly authorized by law to administer oaths in the State of Georgia, _____________________________, Petitioner in the above styled case and on oath states that:

I am the Petitioner in the above styled case and that owing to my poverty I am unable to pay any costs in the foregoing matter. My monthly income is ____________________ and I pay ____________________ per month as rent.

This Affidavit is made pursuant to O.C.G.A. §§ 9-15-2-4 and 15-6-77.

_____________________________________

Sworn to and subscribed before me

this _______ day of ____________, 2________

________________________________

Notary Public

My commission expires _________________

IN THE SUPERIOR COURT OF ______________ COUNTY

STATE OF GEORGIA

_____________________________, ]

]

Petitioner ]

]

V. ] Civil Action File No. _____________

]

_____________________________, ]

]

Respondent ]

ORDER

This Court, having considered the Petitioner’s request to proceed in forma pauperis, hereby grants the request.

This __________ day of _______________________, 2________.

___________________________

Judge, Superior Court

_______________ County