Civil Cover Sheet Page 14
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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.
:
:
_____________________________
:
:
_____________________________
:
Defendant(s)
:
NO. _____________________________
Petition to Proceed In Forma Pauperis
and Without Payment of Bond
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Petitioner, (your name) _________________________________________, seeks
(please print your name)
leave to proceed in this matter in forma pauperis, and respectfully represents that:
1. I am the (indicate plaintiff or defendant) __________________________ in these
proceedings.
Court Term__________________20____and No. ________
Page 3 of 11
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