IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

CIVIL DIVISION

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Plaintiff	:
vs.	:	File No.
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Defendant	:

PETITION FOR LEAVE TO PROCEED

IN FORMA PAUPERIS

TO THE HONORABLE, THE JUDGES OF SAID COURT:

The Petition of respectfully represents:

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.

I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation.

I represent that the information below relating to my ability to pay the fees and costs is true and correct:

(a.)	Name:

Address:
Phone Number:
(b.)	Employment:
If you are presently employed, state:
Employer:
Address:
Salary or wages per month:
Types of work:
If you are presently unemployed, state:
Date of last employment:
Salary or wages per month:
Type of work:
(c.)	Other income within the past twelve months:
Business of profession:
Other self-employment:
Interest:
Dividends:
Pension and annuities:
Social Security benefits:
Support payments:
Disability payments:
Unemployment compensation and supplemental benefits:
Workers’ compensation:
Public assistance:
Other:
(d.)	Other contributions to household support:
Wife’s/Husband’s Name:
If your wife/husband is employed, state:
Employer:
Salary or wages per month:
Type of work:
Contributions from children:
Contributions from parents:
Other Contributions:
(e.)	Property owned
Cash:
Checking account:
Savings account:
Certificates of deposit:
Real Estate (including home):
Motor vehicle:	Make:	Year:
Cost $	Amount Owed $
Stocks and bonds:
Other:
(f.)	Debts and obligations
Mortgage:
Rent:
Loans:
Other:
(g.)	Persons dependent upon you for support
Wife’s/Husband’s Name:
Children, if any:
Name:	Age:
Age:
Age:
Other persons:
Name:
Relationship:

I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances that would permit me to pay the costs incurred herein.

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.

WHEREFORE, Petitioner respectfully prays that the Honorable Court allow the petitioner to proceed in forma pauperis.

Date:

Petitioner

Phone Number: ______________________

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IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

Rachel A Wotring

2023-03-14