__________________, : IN THE COURT OF COMMON PLEAS OF INDIANA COUNTY, PENNSYLVANIA Plaintiff, : vs. : NO.___________C.D.______ __________________, : CIVIL ACTION - LAW CUSTODY Defendant. : 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) Name: ____________________________________________ Address: ___________________________________________ Social Security Number: _______________________________ (b) 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: _______________________________________ (c) 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: _____________________________________________ (d) 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: ____________________________________ (e) Property owned: Cash: ______________________________________________ Checking account: ____________________________________ Savings account: ______________________________________ Certificates of Deposit: _________________________________ Real estate (including home): _____________________________ Motor vehicle: Make _________________, Year ____________,                     Cost _____________, Amount Owed $__________ Stocks; bonds: _______________________________________ Other: ______________________________________________ (f) Debts and Obligations: Mortgage: ___________________________________________ Rent: _______________________________________________ Loans: ______________________________________________ Other: ______________________________________________ ___________________________________________________ (g) Persons dependant upon you for support: Spouses Name: ______________________________________________ Children, if any: ____________________________________ Name: _______________________ Age: _______ _______________________ _______ _______________________ _______ 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: _______________________ ___________________________ Petitioner