Petition For Leave To Proceed In Forma Pauperis - Court Of Common Pleas Of Erie County, Pennsylvania
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1
2:
IN THE COURT OF COMMON PLEAS
___________________________________
:
OF ERIE COUNTY, PENNSYLVANIA
Plaintiff
:
v.
:
NO.
:
___________________________________
:
Defendant
:
:
PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
1. I am the (Plaintiff) (Defendant) 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.
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:
(a) Name: _________________________________________________________________________
Address: _______________________________________________________________________
________________________________________________________________________
(b) Employment
If you are presently employed, state
Employer: ______________________________________________________________________
Address: _______________________________________________________________________
Salary or wages per month: ________________________________________________________
Type of work: ___________________________________________________________________
If you are presently unemployed, state
Date of last employment: _________________________________________________________
Salary or wages per month: ________________________________________________________
Type of work: ___________________________________________________________________
(c) Other income within the past twelve months
Business or profession: ___________________________________________________________
Other self employment: __________________________________________________________
Interest: _______________________________________________________________________
Dividends: _____________________________________________________________________
Pension and annuities: ___________________________________________________________
Social security benefits: ___________________________________________________________
Support payments: ______________________________________________________________
Disability payments: _____________________________________________________________
Unemployment compensation and supplemental benefits: ______________________________
Workers’ compensation: __________________________________________________________
Public assistance: ________________________________________________________________
Other: _________________________________________________________________________
(d) Other contributions to household support
(Wife)(Husband) Name:___________________________________________________________
If your (Wife)(Husband) is employed, state
Employer: ______________________________________________________________________
Salary or wages per month: ________________________________________________________
Type of work: ___________________________________________________________________
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