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

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U.S.A. forms for County of Indiana

BROWSE COUNTY OF INDIANA (PA) FORMS

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1
______________________________
: COURT OF COMMON PLEAS OF
PLAINTIFF : INDIANA COUNTY
: PENNSYLVANIA
v. :
:
_________________________ : No: __________________
DEFENDANT
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: ___________________________________________________________
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: _________________________
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6
_____________________________
: COURT OF COMMON PLEAS OF
PLAINTIFF : INDIANA COUNTY
: PENNSYLVANIA
v. :
:
_________________________ : No: ____________________
DEFENDANT
ORDER OF COURT
AND NOW, this _______ day of ___________________, 20_____, upon presentation
and consideration of the attached, verified Petition to Proceed In Forma Pauperis,
IT IS HEREBY ORDERED THAT:
___________ Petitioner’s request to proceed In Forma Pauperis is GRANTED.
___________ Petitioner’s request to proceed In Forma Pauperis is DENIED.
BY THE COURT:
_______________________
JUDGE
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: COURT OF COMMON PLEAS OF PLAINTIFF : (County of Indiana)

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Completed 6 August 2020

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