MOTION TO PROCEED IN FORMA PAUPERIS PHILADELPHIA COURT OF COMMON PLEAS CONTROL NUMBER: PETITION/MOTION COVER SHEET FOR COURT USE ONLY ANSWER/RESPONSE DATE: (RESPONDING PARTIES MUST INCLUDE THIS NUMBER ON ALL FILINGS) ASSIGNED TO JUDGE: Do not send Judge courtesy copy of Petition/Motion/Answer/Response. Status may be obtained online at http://courts.phila.gov Term, Month Year No. Name of Filing Party: vs. INDICATE NATURE OF DOCUMENT FILED: Petition (Attach Rule to Show Cause) Motion Answer to Petition Response to Motion (Check one) (Check one) Plaintiff Movant Defendant Respondent Has another petition/motion been decided in this case? Yes No Yes Is another petition/motion pending? If the answer to either question is yes, you must identify the judge(s): No TYPE OF PETITION/MOTION (see list on reverse side) PETITION/MOTION CODE (see list on reverse side) MOTION TO PROCEED IN FORMA PAUPERIS MTIFP ANSWER/RESPONSE FILED TO (Please insert the title of the corresponding petition/motion to which you are responding): I. CASE PROGRAM Is this case in the (answer all questions): A. COMMERCE PROGRAM II. PARTIES (Name, address and telephone number of all counsel of record and unrepresented parties. Attach a stamped addressed envelope for each attorney of record and unrepresented party.) Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes No B . DAY FORWARD/MAJOR JURY PROGRAM — Year Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes No C . NON JURY PROGRAM Date Listed: D. ARBITRATION PROGRAM Arbitration Date: E. ARBITRATION APPEAL PROGRAM Date Listed: F. OTHER PROGRAM: Date Listed: III. OTHER By filing this document and signing below, the moving party certifies that this motion, petition, answer or response along with all documents filed, will be served upon all counsel and unrepresented parties as required by rules of Court (see PA. R.C.P. 206.6, Note to 208.2(a), and 440). Furthermore, moving party verifies that the answers made herein are true and correct and understands that sanctions may be imposed for inaccurate or incomplete answers. (Attorney Signature/Unrepresented Party) (Date) (Print Name) (Attorney I.D. No.) The Petition, Motion and Answer or Response, if any, will be forwarded to the Court after the Answer/Response Date. No extension of the Answer/Response Date will be granted even if the parties so stipulate. 30-1061A (Rev. 7/05) American LegalNet, Inc. www.USCourtForms.com