Fillable : COURT OF COMMON PLEAS OF : INDIANA (County of Indiana)

Fill Online, Printable, Fillable, Blank : COURT OF COMMON PLEAS OF : INDIANA (County of Indiana) Form

Use Fill to complete blank online COUNTY OF INDIANA (PA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

: COURT OF COMMON PLEAS OF : INDIANA (County of Indiana)

On average this form takes 25 minutes to complete

The : COURT OF COMMON PLEAS OF : INDIANA (County of Indiana) form is 6 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 94 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of Indiana

BROWSE COUNTY OF INDIANA (PA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
______________________________
: COURT OF COMMON PLEAS OF
: INDIANA COUNTY
: PENNSYLVANIA
v. :
:
_________________________ : No: __________________
AFFIDAVIT IN SUPPORT OF REQUEST FOR WAIVER OF OR REDUCTION OF
TRANSCRIPT COSTS
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 transcript costs.
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 AFFIDAVIT 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: ___________________________________________________________
2
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: $ __________________
3
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: $ __________________________________________________________
4
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: __________________________________ Age: ______
Name: __________________________________ Age: ______
Name: __________________________________ Age: ______
Name: __________________________________ Age: ______
Name: __________________________________ 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.
5
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: _________________________
click to sign
signature
click to edit
6
_____________________________
: COURT OF COMMON PLEAS OF
: INDIANA COUNTY
: PENNSYLVANIA
v. :
:
_________________________ : No: ____________________
ORDER OF COURT
AND NOW, this _______ day of ___________________, 20_____, upon presentation
and consideration of the attached Request for Waiver or Reduction of Transcript Costs and
Affidavit in support thereof, it is hereby Ordered and Directed that:
___The request is DENIED.
___The request is GRANTED and the transcript fees shall be:
___ Waived (if transcript is necessary to advance litigation and party is IFP or
income is less than 125%of poverty guidelines), or
___ Reduced to ___________________ (if transcript is necessary and party’s
income is less than 200% of poverty guidelines), or
___ Reduced to ___________________ (if transcript is not necessary to advance
litigation; however, economic hardship exists and good cause shown.
BY THE COURT:
_______________________
JUDGE
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

: COURT OF COMMON PLEAS OF : INDIANA (County of Indiana)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document