Civil Cover Sheet Page 12
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22First Judicial District of Pennsylvania
Court of Common Pleas of Philadelphia County
Civil Trial Division
___________________________________, pro se
(your name)
___________________________________
___________________________________
(full address)
___________________________________
(area code and telephone number)
___________________________________
:
_____________________Term, 20_________
:
(month)
(year)
___________________________________
:
Plaintiff(s)
:
:
VS.
:
:
:
___________________________________
:
:
___________________________________
:
NO._________________________________
Defendant(s)
In Forma Pauperis Order
AND NOW, this ____________day of ________________________, 20_______ , it is
hereby ORDERED AND DECREED that:
1. Petitioner be permitted to proceed without paying the costs of this proceeding or
posting a bond.
2. Petitioner be permitted to obtain service of the papers filed without cost.
3. Petitioner be permitted to proceed in forma pauperis as to any additional costs
which accrue in the course of this proceeding.
(IFP/REV.10/2000)
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