Civil Cover Sheet Page 21
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22Relationship: __________________________________________________________
4. I understand that I have a continuing obligation to inform the Court of improvement in my
financial circumstances which 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. §4904, relating to unsworn
falsification to authorities.
Dated: ____________________
__________________________________________
Petitioner
(Print your name)
__________________________________________
Petitioner
(Sign your name)
Sworn to and subscribed before me this
______ day of ______________,20______.
__________________________________
Notary Public
Page 10 of 11
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