Petition To Proceed In Forma Pauperis Page 5
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11First Judicial District of Pennsylvania
Court of Common Pleas of Philadelphia County
Trial Division – Civil
, pro se
(your name)
(full address)
(area code and telephone number)
:
, TERM, 20
:
(month)
(year)
:
Plaintiff(s)
:
:
VS.
:
:
:
NO.
:
:
:
Defendant(s)
:
Petition to Proceed In Forma Pauperis
and Without Payment of Bond
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Petitioner, (Please Print Your Name)
, seeks leave to proceed in this
matter in forma pauperis, and respectfully represents that:
1. I am the (indicate plaintiff or defendant)
in these proceedings.
2. I reside at (state your full address)
3. I have listed my sources and amounts of income truly and correctly on the attached affidavit.
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