Petition To Proceed In Forma Pauperis Instruction Sheet Page 7
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10You do not need to fill out this petition if you receive benefits from the
Department of Human Services or the Social Security Administration.
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
:
:
FAMILY COURT DIVISION
Plaintiff
:
Custody
Partial Custody
:
Visitation
Support
vs.
:
:
D.R. No.:
:
Defendant
:
PACSES No.:
:
POVERTY AFFIDAVIT
1.
I,
am the (check one)
PLAINTIFF
DEFENDANT in a
support/custody matter, and because of my financial condition I 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 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:
Social Security Number:
Employment:
(b)
If you are presently employed, state:
Employer:
Employer Address: ____________________________________________
Annual or Monthly Gross Salary (please specify):
Type of Work:
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