Appointment Of Authorized Representative Form (Rules 102 And 131) - Philadelphia Municipal Court
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1IN THE PHILADELPHIA MUNICIPAL COURT
NO.
PLAINTIFF(S)
DEFENDANT(S)
APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM (RULES 102 AND 131)
The following section is to be completed by the individual on behalf of the party that is appointing an Authorized Representative:
I, _________________________________, on behalf of__________________________________
Name of Appointing Individual
Name of Party
a party in the above-captioned matter, do hereby certify that the party is one of the following: (check one)
an individual or sole proprietor;
a corporation;
a general partnership;
a limited partnership;
a limited liability company;
a professional association; or
a business trust.
I further certify that I have authority to execute this form on behalf of the party and that I am: (check one)
the individual or sole proprietor that is the party;
an officer of the corporation that is the party;
a partner of the general
partnership that is the party;
a general partner of the limited partnership that is the party;
a manager of the limited liability
company that is the party;
an officer of the board of governors of the professional association that is the party; or
a trustee of
the business trust that is the party.
I hereby authorize____________________________________ to act as an Authorized Representative of the party named
above and certify that the Authorized Representative has personal knowledge of the facts and circumstances of the above-captioned
matter and is acting as an agent of the party. The nature and extent of the authorized representative’s authority is limited to the
following: (check as many as are applicable)
filing a statement of claim;
filing a landlord tenant complaint;
negotiating an amicable resolution of the matter;
participating at trial by testifying, submitting documents into evidence, asking questions of witnesses and making argument, and
filing or responding to a petition to open a default judgment.
I hereby verify that the facts set forth above are true and correct to the best of my knowledge, information and belief. I
further acknowledge that this verification is made subject to the penalties for making an unsworn falsification to authorities in violation
of 18 Pa. C.S. § 4904.
Printed Name: _______________________________
___________________________________
Signature of Appointing Individual
Date: ________________________________
The following section is to be completed by the Authorized Representative:
I, __________________________________, do hereby verify, to the best of my knowledge, information and belief, that I
have personal knowledge of the facts and circumstances of the above-captioned matter. I further acknowledge that this verification is
made subject to the penalties for making an unsworn falsification to authorities in violation of 18 Pa. C.S. § 4904.
Printed Name: _______________________________
___________________________________
Signature of Authorized Representative
Date:________________________________
Telephone: ___________________________
Date: _______________________________
03-127W (Rev. 4/11)
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