Petition For Leave To Proceed In Forma Pauperis

IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA MOTION FAMILY/MISCELLANEOUS COURT DIVISION : : : Plaintiff : : vs. : File No: : : Defendant : PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS TO THE HONORABLE, THE JUDGES OF SAID COURT: The Petition of respectfully represents: 1. I am the plaintiff/defendant in the above matter and because of my financial condition 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 Number: (b.) Employment: If you are presently employed, state: Employer: Address: Salary or wages per month: Types of work: If you are presently unemployed, state: Date of last employment: Salary or wages per month: Type of work: <<<<<<<<<********>>>>>>>>>>>>> 2 (c.) Other income within the past twelve months: Business of profession: Other self-employment: Interest: Dividends: Pension and annuities: Social Security benefits: Support payments: Disability payments: Unemployment compensation and supplemental benefits: Workmans compensation: Public assistance: Other: (d.) Other contributions to household support: Wifes/Husbands Name: If your wife/husband is employed, state: Employer: Salary or wages per month: Type of work: Contributions from children: Contributions from parents: Other Contributions: (e.) Property owned Cash: Checking account: Savings account: Certificates of deposit: Real Estate (including home ): Motor vehicle: Make: , Year Cost $ , Amount Owed $ Stocks; bonds: Other: (f.) Debts and obligations Mortgage: Rent: Loans: Other: Page 2 <<<<<<<<<********>>>>>>>>>>>>> 3 (g.) Persons dependent upon you for support Wifes/Husbands Name: Children, if any: Name: Age: Age: Age: Other persons: Name: Relationship: 4. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances that 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. WHEREFORE, Petitioner respectfully prays that the Honorable Court allow the petitioner to proceed in forma pauperis. Date: Petitioner Page 3