(Caption)
Address: ______________________________________
_________________________
If you are presently employed, state
Employer: ______________________________________
Address: ______________________________________
________________________________
Salary or wages per month: ______________________________________
Type of work: ______________________________________
If you are presently unemployed, state
Date of last employment: ______________________________________
Salary or wages per month: ______________________________________
Type of work: ______________________________________
Business or 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: ______________________________________
______________________________________
If your (wife) (husband) is employed, state
Employer: ______________________________________
Salary or wages per month: ______________________________________
Type of work: ______________________________________
Contributions from children: ______________________________________
Contributions from parents: ______________________________________
Other contributions: ______________________________________
Cash: ______________________________________
Checking account: ______________________________________
Savings account: ______________________________________
Certificates of deposit: ______________________________________
Real estate (including home): ______________________________________
Motor vehicle: Make ____________ , Year ____________
Cost ____________ , Amount Owed $ ___
Stocks and bonds: ______________________________________
Other: ______________________________________
Mortgage: ______________________________________
Rent: ______________________________________
Loans: ______________________________________
Other: ______________________________________
______________________________________
(Wife) (Husband) Name: ___________________________
Children, if any:
Initials: ____________________________ Age: ____________
_________________________________ ____________
_________________________________ ____________
Other Persons:Name: ______________________________________
Relationships: ______________________________________
Date: ____________
____________
Petitioner
(Caption)
PRAECIPE TO PROCEED IN FORMA PAUPERIS
To the Prothonotary:
Kindly allow _________________________, (Plaintiff) (Defendant) to proceed in forma pauperis.
I, _________________________, attorney for the party proceeding in forma pauperis, certify that I believe the party is unable to pay the costs and that I am providing free legal service to the party.
________________________________
Attorney for
231 Pa. Code r. 240