Petition For Leave To Proceed In Forma Pauperis - Court Of Common Pleas Of Erie County, Pennsylvania Page 2
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2Contributions from children: _______________________________________________________
Contributions from parents: _______________________________________________________
Other contributions: _____________________________________________________________
(e) Property owned
Cash: _________________________________________________________________________
Checking account: _______________________________________________________________
Savings account: ________________________________________________________________
Certificates of Deposit: ___________________________________________________________
Real estate (including home): ______________________________________________________
Motor vehicle: Make __________________________, Year ________, Cost _______, Amount
Owed $________________________________________________________________________
Stocks and bonds: _______________________________________________________________
Other: _________________________________________________________________________
(f) Debts and obligations
Mortgage: _____________________________________________________________________
Rent: __________________________________________________________________________
Loans: _________________________________________________________________________
Other: _________________________________________________________________________
(g) Persons dependent upon you for support
(Wife)(Husband) Name: ___________________________________________________________
Children, if any:
Name & Age: ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other persons:
Name: ________________________________________________________________________
Relationship: ___________________________________________________________________
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. Sect. 4904, relating to
unsworn falsification to authorities.
Wherefore, I request this Honorable Court to enter an Order granting me leave to file an action as
an indigent party without the necessity of paying any filing fees or costs.
Date: _______________________ Petitioner: _____________________________________
ORDER
AND NOW, to‐wit, this ________ day of _________________________, the above
Petition for Leave to Proceed In Forma Pauperis is _______________ as it pertains to the filing
fees and costs in this matter.
BY THE COURT:
________________________________
Judge
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