______________________________ PLAINTIFF v. _________________________ DEFENDANT : : : : : : COURT OF COMMON PLEAS OF INDIANA COUNTY PENNSYLVANIA No: __________________ PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS 1. I am the Plaintiff / Defendant (Circle One) in the above matter and due to my current financial condition I am unable to pay the costs and fees of prosecuting or defending this action or proceeding. 2. I am unable to obtain funds from anyone, including my family and associates, to pay these costs. 3. I am proceeding pro se in this action because I cannot afford legal services. 4. I represent that the information below relating to my ability to pay the fees and costs is true and correct: {Note to filer: THIS PETITION MUST BE COMPLETED IN ITS ENTIRETY. If a section does not apply to you, write "N/A" or if the amount is zero write "0".} (a) Name: ____________________________________________________________ Address: __________________________________________________________ __________________________________________________________ Social Security Number: (last 4 number only)________________________________ Email: _____________________________ Phone Number: ____________________ (b) Employment: (i). If you are presently employed, complete this section. Employer: ___________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com Address: ____________________________________________________________ Email: _____________________________ Phone Number: ___________________ Salary or wages per month: ______________________________________________ Type of work: ________________________________________________________ (ii). If you are presently unemployed, complete this section. Date of last employment: ____________________________________________ Salary or wages per month: __________________________________________ Type of work: _____________________________________________________ (iii) If you are presently self-employed, complete this section, along with section (b) (i) of this petition. Average net income (annual) of profession and/or business: $________________ (c) Other income received within the past twelve months: (Write the gross amount (i.e. before taxes) per month that you received and the months you received this income). Business or profession: $ ___________________ Self-employment: $_______________________ Interest: $ _______________________________ Dividends: $_____________________________ Pensions and annuities: $ ___________________ Social Security Benefits: $ __________________ Spousal or Child Support payments: $________________ Disability payments: $ ____________________________ Unemployment compensation and supplemental benefits: $ _________________ Workers' Compensation: $ __________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com Public Assistance: $ _______________________ Other: Food Stamps: $ ____________________ Medical Assistance: $ __________________ Total Income within the past twelve months: $_________________ (d) Other contributions to household support by other adult household members: (Write the gross amount (i.e. before taxes) per month that you received and the months you received this income). Names: ________________________________________________________________ Are any adult household members employed? ____Yes ____No Salary or wages per month: $ ___________________ Type of work: _______________________________ Other contributions to household expenses: $_________________________ (e) Property owned: Cash: $ _____________________________________________________________ Checking account: $ __________________________________________________ Savings account: $ ____________________________________________________ Certificates of Deposit: $ _______________________________________________ Real Estate (including home): __________________________________________ Motor Vehicle: Make: _____________ Year: ____________ Cost: ______________ Amount Owed: _________________ Stocks and bonds: $ ____________________________________________________ Other: $ _____________________________________________________________ (f) Debts and Obligations: Mortgage: $ __________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com Rent: $______________________________________________________________ Loans: $_____________________________________________________________ Other: $ _____________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ (In the above lines labeled "Other": Include all of your regular monthly bills, phone, utilities, cable, insurance, etc.) 5. My biological or adopted child(ren) who primarily resides with me include: Name: __________________________________ Name: __________________________________ Name: __________________________________ Name: __________________________________ Name: __________________________________ Age: ______ Age: ______ Age: ______ Age: ______ Age: ______ 6. Other person(s) in my household who are dependent upon me for financial support include: Name: __________________________________ Age: ______ Relationship: ________________________ Why dependent? ______________________ Name: __________________________________ Age: ______ Relationship: ________________________ Why dependent? ______________________ Name: __________________________________ Age: ______ Relationship: ________________________ Why dependent? ______________________ 7. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances. Also, I understand that the granting of this petition will only provide relief of the filing fees of this case. 4 American LegalNet, Inc. www.FormsWorkFlow.com 8. 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. � 4904, relating to unsworn falsification to authorities. Date: _________________ Signature of Petitioner: ____________________________ Printed Name of Petitioner: _________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com _____________________________ PLAINTIFF v. _________________________ DEFENDANT : : : : : : COURT OF COMMON PLEAS OF INDIANA COUNTY PENNSYLVANIA No: ____________________ ORDER OF COURT AND NOW, this _______ da