STATE OF SOUTH CAROLINA,	)
)	IN THE COURT OF COMMON PLEAS
COUNTY OF	)
)	JUDICIAL CIRCUIT
)
Plaintiff	)	MOTION AND AFFIDAVIT TO
)	PROCEED IN FORMA PAUPERIS
vs.	)
)
)
Defendant.	)	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	)	Signature of Plaintiff or
Person Filing Complaint on Behalf of Plaintiff
)
My Commission expires	)

ORDER

Leave is granted to proceed in forma pauperis without payment of the filing fee.

Leave is granted to proceed in forma pauperis without payment of the service cost.

Leave is denied to proceed in forma pauperis.

Dated:	, 2
JUDGE/CLERK OF COURT
,	South Carolina

NOTICE TO PLAINTIFF:	The Court may assess costs against either party at hearing.

SCCA 405CP (10/10)

STATE OF SOUTH CAROLINA,

SCJD

2010-10-28

wclark

SC Judicial Dept