___________________________________ : IN THE COURT OF COMMON PLEAS Plaintiff : : OF LACKAWANNA COUNTY VS. : : FAMILY COURT - DIVISION ___________________________________ : Defendant : ______ FC ______ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ORDER AND NOW, this _________day of ________________________20__, upon consideration of the application to proceed in forma pauperis, which was filed by the above Plaintiff, ________________________in accordance with Rule No. 1920.62 of the Pennsylvania Rules of Civil Procedure, IT APPEARING TO THE COURT that the said is an indigent and unable to pay the filing fees for service of process costs; the request for permission to proceed in forma pauperis is granted. BY THE COURT: ________________________________J. American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________ : IN THE COURT OF COMMON PLEAS Plaintiff : : OF LACKAWANNA COUNTY VS. : : FAMILY COURT - DIVISION ___________________________________ : Defendant : ______ FC ______ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: PETITION AND AFFIDAVIT 1. I am the (Plaintiff) (Defendant) in the above matter and because of my financial condition(s) I 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 No. ___________________________________________ (b) Employment If you are presently employed, state Employer____________________________________________________ Address_____________________________________________________ _____________________________________________________ Salary or wage per month_______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Type of work_________________________________________________ If you are presently unemployed, state Date of last employment________________________________________ Salary of 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 (Wife) (Husband) Name_______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com If your (wife) (husband) is employed, state Employer_________________________________________________ Salary or wages per month______________________________________ Type of Work________________________________________________ Contributions from children_____________________________________ Other contributions____________________________________________ (e) Property Owned Cash________________________________________________________ Checking Account_____________________________________________ Saving Account_______________________________________________ Certificate of Deposit__________________________________________ Real Estate (including home)____________________________________ Motor Vehicle Make___________________________________________ Year_______________________Cost_____________________________ Amount Owed $______________________________________________ Stocks, Bonds________________________________________________ Other_______________________________________________________ (f) Debts and Obligations Mortgage____________________________________________________ Rent________________________________________________________ Loans_______________________________________________________ Other_______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com (g) Persons dependant upon you for support (Wife) (Husband) 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. 4904, relating to unsworn falsification to authorities. Date______________________________________ ____________________________________ Petitioner American LegalNet, Inc. www.FormsWorkFlow.com