COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IN THE COURT OF COMMON PLEAS:::::::Index No.Plaintiffv.Calendar No.OF ERIE COUNTY, PENNSYLVANIA CIVIL DIVISIONJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)DefendantNO.PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS1. I am the (Plaintiff) (Defendant) listed above. Because of my financial condition, I am unableto pay the required fees. 2. Have you ever applied for an In Forma Pauperis (IFP) in the past? yes no.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If so, was it granted? yes no. If not, please state why. 3. If you have petitioned for an IFP in the past, have your financial circumstances changedTHE PEOPLE OF THE STATE OF NEW YORK TOsince the last request? yes no. If yes, please briefly explain that change. .4. I am unable to obtain funds from anyone, including my family and friends, to pay the costs. 5. I represent that the information below relating to my ability to pay the fees and costs is trueGREETINGS:and correct: a. Name: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofAddress: City, State, & ZIP: Social Security Number: o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomb. EMPLOYMENTYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.If presently employed, state Employer: Address: City, State, & ZIP: Wages/salary per month: Type of work: If presently unemployed, state date of last employment: Wages/salary per month: Type of work: Reason no longer employed at last job: , one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)c. OTHER INCOME WITHIN PAST TWELVE MONTHSAttorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Business/Profession: Other self-employment: Interest: Dividends: Pension and annuities: Social Security benefits: Support payments: Disability payments: Unemployment compensation and supplemental benefits: Workers' compensation: Public Assistance: Other: d. OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORTMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name of spouse/significant other: If your spouse if employed, state employer: Wages/salary per month: Type of work: Contributions from Children: Contributions from Parents: Other contributions: :::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)e. PROPERTY OWNED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cash: Checking Account: Savings Account: Certificates of Deposit: Real Estate (including home): Motor vehicle: Make: Year: Cost: Amount now owed: THE PEOPLE OF THE STATE OF NEW YORK TOStocks/bonds: Other: f. DEBTS AND OBLIGATIONSMortgage: Rent: Loans: Other: GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorableg. PERSONS DEPENDENT UPON YOU FOR SUPPORT,Name of spouse: Children, if any: Name: Age: located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room Age: Age: Other persons: Name: Relationship: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.6. I understand that I have a continuing obligation to inform the Court of any improvement in, one of the Justices of themy financial circumstances which would permit me to pay the costs. 7. I verify that the statements made in this Affidavit are true and correct. I understand thatCourt in Witness, Honorableday of, 20 County,false statements are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. Wherefore, I request this Honorable Court to enter an Order granting me leave to file an action(Attorney must sign above and type name below)as an indigent party without the necessity of paying any filing fees or costs.Attorney(s) forDATE: Petitioner: ORDEROffice and P.O. AddressAND NOW, to-wit, this day of , the abovePetition for Leave to Proceed In Forma Pauperis is as it pertains to the filing fees of the Prothonotary office in this matter.Telephone No.: Facsimile No.: E-Mail Address:BY THE COURT: JudgeMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com