Fillable In Forma Pauperis Petition (Delaware County Courthouse and Government Center)

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In Forma Pauperis Petition (Delaware County Courthouse and Government Center)

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1
IN THE COURT OF COMMON PLEAS OF DELAWARE COUNTY, PENNSYLVANIA
______________________________ : NO. __________________________
Plaintiff :
:
v. :
:
______________________________ :
Defendant :
PETITION TO PROCEED IN FORMA PAUPERIS
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 this
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.
4. Please answer all questions.
5. You may be required to attend a Court Hearing and provide evidence in
support of your request to proceed In Forma Pauperis
(a) Name: ____________________________________________________________
Address: __________________________________________________________
__________________________________________________________
Phone Number _____________________
Email Address: ____________________ ___________
(b) Employment
If you are presently employed, state the following:
Employer: ______________________________________
2
Address: ______________________________________
______________________________________
Salary or wages per month: _______________
Type of Work: _________________
You must attach a copy of the following documentation:
1. Your most recent Federal and State Income Tax Return.
2. Your most recent year to date pay stub for you.
If you are presently unemployed, state the following:
Date of Last Employment: ____________________
Salary or Wages per Month: ___________________
Type of Work: ______________________________
Please attach a copy of the following documentation:
1. Letter of grant/denial of unemployment or worker’s compensation OR
2. Statement of unemployment compensation or worker’s compensation.
(c) Other income within the past twelve (12) months:
Please attach documentation for each form of income listed below that you
receive.
1. Business or Profession: _________________________________________
2. Are you the beneficiary of any Trust, Annuity or Settlement: Yes ___ No ___
Please explain and provide documentation: ____________________________
_______________________________________________________________
3
3. Self-Employment: ________________________________________
4. Interest: ________________________________________________
5. Dividends: ______________________________________________
6. Investments: _____________________________________________
7. Pension and/or Annuities: __________________________________
8. Social Security Benefits: ___________________________________
9. Support Payments: _______________________________________
10. Disability Payments: ______________________________________
11. Unemployment Compensation and Supplemental Benefits: ________
________________________________________________________
12. Workmen’s Compensation: _________________________________
13. Public Assistance: ________________________________________
14. Contributions from Parents: _________________________________
15. Contributions from Children: ________________________________
16. Other: __________________________________________________
________________________________________________________
(d) Please list any other adult members of your household and their income
1. Name: ________________________________________________
Source of Income: ______________________________________
Amount of Income ___________ Month _________ Year _____
2. Name: ________________________________________________
4
Source of Income: ______________________________________
Amount of Income ___________ Month _________ Year _____
(e) Property Owned
Cash: ______________________________________________________
Checking Account(s): _________________________________________
Savings Account(s): __________________________________________
Certificate(s) of Deposit: ______________________________________
Real Estate (including home): __________________________________
___________________________________________________________
Motor Vehicles: Make: __________________ Year: ___________
Cost: __________________
Amount Owed: $______________
Make: __________________ Year: ___________
Cost: ___________________
Amount Owed: $ _____________
Stocks and Bonds: _____________________________________________
Other: _______________________________________________________
(f) Debts and Obligations
Mortgage: ___________________________________________________
Rent: _______________________________________________________
Loan(s): ____________________________________________________
Other: ______________________________________________________
______________________________________________________
5
(g) Persons dependent upon you for support:
Spouse’s Name: _____________________________________________
Children, if any:
Name: ________________________________________ Age: ______
________________________________________ ______
_________________________________________ ______
_________________________________________ ______
Other Persons:
Name: ________________________________________________
Relationship: __________________________________________
6. I understand that I have a continuing obligation to inform the Court of
improvements in my financial circumstances which would permit me to pay the
costs incurred herein.
7. I further understand that if my Petition is approved, the Order shall allow only for
the waiver of the one filing fee/cost for this action. Waiver of any other costs will
require the filing of another Petition and Affidavit with supporting documentation.
8. I verify that the statements made in this affidavit are true and correct. I understand
that false statements herein are subject to the penalties outlined in 18 Pa.C.S.
§4904, relating to unsworn falsification to authorities.
PETITIONER: __________________________________________________________
DATE: ___________________________________________________________
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In Forma Pauperis Petition (Delaware County Courthouse and Government Center)

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Completed 24 July 2020

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