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IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania)

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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
CIVIL DIVISION
PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS COVER SHEET
Plaintiff(s):
Case Number:
- -
Filed on behalf of:
VS. (Name of the filing party)
Defendant(s): Counsel of Record
Individual, If Pro Se
Name, Address,
Telephone Number
, and
E-mail Address:
Attorney’s State ID:
Attorney’s Firm ID:
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
DEPARTMENT OF COURT RECORDS CIVIL/FAMILY DIVISION
NO. ___________________________
VS
PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
AND NOW, comes the (plaintiff/defendant) ____________________________________________,
and respectfully requests this Honorable Court for “Leave to Proceed In Forma Pauperis” in the
above captioned case. In support of this Petition, (plaintiff/defendant) avers as follows:
1. Plaintiff/Defendant desires to (commence a Civil Action/Appeal) to the Court of Common
Pleas but is without the funds to pay the filing fee.
2. Plaintiff’s/Defendant’s financial affairs are set forth in a verified statement, a copy of which is
attached to this petition as “Exhibit A”.
3. If plaintiff/defendant is not permitted to commence a Civil Action/Appeal In Forma Pauperis,
they will be denied due process of Law and his/her rights under the Constitution of the United
States and the Constitution of the Commonwealth of Pennsylvania.
WHEREFORE, plaintiff/defendant prays this Honorable Court to grant this Petition and to allow
him/her to proceed without payment of the required fees.
Respectfully submitted,
____________________________________________
Plaintiff/Defendant
IN THE COURT OF COMMON PLEAS
ALLEGHENY COUNTY, PENNSYLVANIA
DEPARTMENT OF COURT RECORDS CIVIL/FAMILY DIVISION
Exhibit A
_____________________________________
_____________________________________
NO. ___________________________
VS IN FORMA PAUPERIS
VERIFIED STATEMENT
_____________________________________
_____________________________________
1. I am the plaintiff/defendant in the above matter and because of my financial condition; 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. N
ame _________________________________
B. A
ddress________________________________ City__________ State_____ Zip______
C. Phone_________________________________
D. EMPLOYMENT
If you are presently employed, complete the following:
Employer Name and address: _________________________________________________
_________
________________________________________
Employer phone number: _________________________ Employee ID#________________
Monthly salary or wages $______________ Type of work: ___________________________
If you are presently unemployed, complete the following:
Date last worked: _____________________ Monthly salary or wages: $________________
Type of work: ______________________________________________________________
E. OTHER INCOME WITHIN THE PAST 12 MONTHS (list amounts for each and explain)
Business or professional $_____________________________________________
Other self-employment $_____________________________________________
Interest earned $_____________________________________________
Dividends $_____________________________________________
Pension or Annuities $_____________________________________________
Social Security Benefits $______________________________________________
Support payments $______________________________________________
Disability payments $______________________________________________
Unemployment or Supplemental benefits $__________________________________
Worker’s Comp $_______________________________________________
Public Assistance $_______________________________________________
Other $_______________________________________________
Explanation ________________________________________________
F. OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT:
Name: ________________________________________________________________
Name of Employer________________________________________________________
Employer address: _______________________________________________________
City____________________ State________ Zip_________ Phone______________
Type of work
_________________________________________________________
Monthly salary or wages $_______________________________________________
Contributions from children $______________Contribution from parents $____________
Other contributions (explain) $_______________________________________________
G. PROPERTY OWNED:
Cash $________________ Checking $_____________ Savings $______________
Certificates of Deposit (CD) $____________Real Estate including house $____________
Motor vehicle(s) Make___________ Model_________________ Year___________
Purchase price $_____________ Amount owed $______________
Make___________ Model_________________ Year___________
Purchase price $_____________ Amount owed $______________
Stocks/Bonds $__________________________________________________________
Other (explain) $_________________________________________________________
H. DEBTS AND OBLIGATIONS: (Identify in detail expenses; i.e. those recurring monthly or
annual payments – be specific in description.)
Mortgage $____________ Rent $__________ Loans $_______________
Other (explain)
$___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I. PERSONS DEPENDENT UPON YOU FOR SUPPORT:
Spouse Name________________________________________________________
Number of Children (if any):__________
Age______________
Age______________
Age______________
Age______________
Age
_____________
Other persons:
Name____________________________ Relationship___________________
Name____________________________ Relationship___________________
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. paragraph 4904, relating
to unsworn falsification to authorities.
___________________________________________ _____________________
Petitioner Date
COURT OF COMMON PLEAS
ALLEGHENY COUNTY, PENNSYLVANIA
____________________________
____________________________
____________________________
vs NO._____________________
____________________________
____________________________
____________________________
ORDER OF COURT
AND NOW, to wit, this ___________ day of _________________________ 2020,
upon consideration of the foregoing Petition, it is hereby ORDERED, ADJUDGED and DECREED
that the Petitioner be and hereby is permitted to file and pursue his/her appeal/action in the above
captioned case without payment of costs or fees.
BY THE COURT
______________________________________
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania)

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Completed 16 May 2021

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