COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : __________________, : Index No. Calendar No. IN THE COURT OF COMMON PLEAS OF INDIANA COUNTY, : JUDICIAL Plaintiff(s) PENNSYLVANIA SUBPOENA : Plaintiff, -against: vs. : NO.___________C.D.______ : __________________, : CIVIL ACTION - LAW : Defendant. : Defendant(s) : . . . . AFFIDAVIT .AND. PETITION. TO.PROCEED. IN. FORMA ............ .... .......... ... .......... .. ... PAUPERIS THE1. I am the ______________ in the YORK matter and because of my PEOPLE OF THE STATE OF NEW above financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding. TO 2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation. GREETINGS: 3. I represent that the information below relating to my ability to pay WE COMMAND YOU, that the fees and costs is true and correct: all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of ____________________________________________ (a) Name: in room , on the day of , 20 , at o'clock in the noon, and at any recessed Address: ___________________________________________ or adjournedSecuritytestify and _______________________________ the part of the date, to Number: give evidence as a witness in this action on Social (b) Employment: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to If you are presently employed, state: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Employer: __________________________________________ result of your failure to comply. Address: ___________________________________________ Salary or wages per month: _____________________________ TypeWitness, Honorable of work: _______________________________________ , one of the Justices of the presently day of Court in If you are County, unemployed, state , 20 Date of last employment: _______________________________ Salary or wages per month: _____________________________ Type of work: _______________________________________ (Attorney must sign above and type name below) (c) Other income within the past twelve months: Business or profession: ________________________________ for Attorney(s) Other self-employment: ________________________________ Interest: ____________________________________________ Dividends: __________________________________________ Pension and annuities: _________________________________ P.O. Address Office and Social security benefits: ________________________________ Support payments: ____________________________________ Disability payments: ___________________________________ Telephone No.: Unemployment compensation and supplemental benefits: Facsimile __________________________________________________ No.: E-Mail Address: Workman's compensation: ______________________________ Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : (d) Index No. Calendar No. Public assistance: _____________________________________ : Other: _____________________________________________JUDICIAL SUBPOENA Plaintiff(s) Other contributions to household support: -against- : Spouse's Name: ______________________________________ : If your spouse is employed, state _____________________ Employer: ___________________________________________ : Salary or wages per month: ______________________________ Type of work: ________________________________________ Defendant(s) : . . . . Contributions .from . . . . . . . . .______________________________ . . . . . . . . . . . . . . . . children: . . . . . . . . . . . . . . . . . . . . . . . . Contributions from parents: ______________________________ Other contributions: ____________________________________ (e) Property owned: STATE OF NEW YORK THE PEOPLE OF THE TO Cash: ______________________________________________ Checking account: ____________________________________ Savings account: ______________________________________ Certificates of Deposit: _________________________________ GREETINGS: (including home): _____________________________ Real estate Motor vehicle: Make _________________, Year ____________, WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Cost _____________, Amount Owed $__________ , the Honorable at the Court Stocks; bonds: _______________________________________ located at County of ______________________________________________ Other: in room , on the , 20 , at o'clock in the noon, and at any recessed (f) Debts and Obligations: day of or adjourned date, to testify and give evidence as a witness in this action on the part of the Mortgage: ___________________________________________ Rent: _______________________________________________ Loans: ______________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Other: whose behalf this subpoena was issued for a maximum penalty the party on ______________________________________________ of $50 and all damages sustained as a result of your failure to comply. ___________________________________________________ (g) Persons dependant upon you for support: Witness, Honorable , one of the Justices of the Court in County, day of , 20 Spouses Name: ______________________________________________ Children, if any: ____________________________________ (Attorney must sign above and type name below) Name: _______________________ Age: _______ _______________________ _______ _______________________ _______ Attorney(s) for Other persons: Name: ____________________________________________ Relationship: ____________________________________ Office and P.O. Address 4. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances which Telephone No.: would permit me to pay the costs incurred herein. Facsimile No.: E-Mail true 5. I verify that the statements made in this affidavit are Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. and correct. I understand that false statements herein are made : subject to the penalties of 18 Pa. C.S. section 4904, relating to JUDICIAL SUBPOENA Plaintiff(s) unsworn falsification to authorities. -against- : Date: _______________________ : : ___________________________ Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Petitioner . . . . . . . . . . . ........ THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 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. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com