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IN THE COURT OF COMMON PLEAS OF INDIANA COUNTY, PENNSYLVANIA |
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NO.___________C.D.______ |
| __________________, |
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CIVIL ACTION - LAW CUSTODY |
AFFIDAVIT AND PETITION TO PROCEED IN FORMA PAUPERIS
1. I am the ______________ in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding.
2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation.
3. I represent that the information below relating to my ability to pay the fees and costs is true and correct:
| (a) |
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Name: ____________________________________________
Address: ___________________________________________
Social Security Number: _______________________________ |
| (b) |
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Employment:
If you are presently employed, state:
Employer: __________________________________________
Address: ___________________________________________
Salary or wages per month: _____________________________
Type of work: _______________________________________
If you are presently unemployed, state
Date of last employment: _______________________________
Salary or wages per month: _____________________________
Type of work: _______________________________________
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| (c) |
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Other income within the past twelve months:
Business or profession: ________________________________
Other self-employment: ________________________________
Interest: ____________________________________________
Dividends: __________________________________________
Pension and annuities: _________________________________
Social security benefits: ________________________________
Support payments: ____________________________________
Disability payments: ___________________________________
Unemployment compensation and supplemental benefits:
__________________________________________________
Workman's compensation: ______________________________
Public assistance: _____________________________________
Other: _____________________________________________
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| (d) |
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Other contributions to household support:
Spouse's Name: ______________________________________
If your spouse is employed, state _____________________
Employer: ___________________________________________
Salary or wages per month: ______________________________
Type of work: ________________________________________
Contributions from children: ______________________________
Contributions from parents: ______________________________
Other contributions: ____________________________________
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| (e) |
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Property owned:
Cash: ______________________________________________
Checking account: ____________________________________
Savings account: ______________________________________
Certificates of Deposit: _________________________________
Real estate (including home): _____________________________
Motor vehicle: Make _________________, Year ____________,
Cost _____________, Amount Owed $__________
Stocks; bonds: _______________________________________
Other: ______________________________________________
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| (f) |
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Debts and Obligations:
Mortgage: ___________________________________________
Rent: _______________________________________________
Loans: ______________________________________________
Other: ______________________________________________
___________________________________________________
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| (g) |
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Persons dependant upon you for support:
Spouses Name: ______________________________________________
Children, if any: ____________________________________
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Name: |
_______________________ |
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Age: |
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_______________________ |
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_______________________ |
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Other persons:
Name: ____________________________________________
Relationship: ____________________________________
4. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances which would permit me to pay the costs incurred herein.
5. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. section 4904, relating to unsworn falsification to authorities.
| Date: _______________________ |
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___________________________
Petitioner |
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