Petition To Proceed In Forma Pauperis Page 7
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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)
:
Petitioner’s Affidavit
Pursuant to PA. R.C.P. 240
COMMONWEALTH OF PENNSYLVANIA
:
:
SS.
COUNTY OF PHILADELPHIA
:
1. I,
, am the (Plaintiff) (Defendant) in the above matter and
because of my financial condition 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 my 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:
Page 4 of 8
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