Civil Cover Sheet Page 17
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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. _______________________________
Petitioner’s Affidavit
Pursuant to PA. R.C.P. 240
COMMONWEALTH OF PENNSYLVANIA
:
:
SS.
COUNTY OF PHILADELPHIA
:
1. I, _________________________________________, am the (Plaintiff) (Defendant)
(circle one)
in the above matter and because of my financial condition am unable to pay the fees
and costs of prosecuting or defending the action or proceeding.
Page 6 of 11
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