Petition To Proceed In Forma Pauperis Page 10
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11Other 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. §4904, relating to unsworn falsification to authorities.
Petitioner
(Print your name)
Date:
Petitioner
(Sign your name)
Page 7 of 8
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