Except as prescribed by subparagraph (3), the magisterial district judge shall act promptly upon the petition and shall enter a determination within five days from the date of the filing of the petition. If the petition is denied, in whole or in part, the magisterial district judge shall briefly state the reasons therefor. The unsuccessful petitioner may proceed no further so long as such costs remain unpaid.
The magisterial district judge shall inform a party permitted to proceed in forma pauperis of the option to serve the complaint by mail in the manner permitted by these rules.
A party permitted to proceed in forma pauperis has a continuing obligation to inform the court of improvement in the party's financial circumstances which will enable the party to pay costs.
[Caption]
Petition
I hereby request that I be permitted to proceed in forma pauperis (without payment of the filing and service costs). In support of this I state the following:
Address: ___________________________
If you are presently employed, state
Employer: ___________________________
Address: ___________________________
Salary or wages per month: ___________________________
Type of work: ___________________________
If you are presently unemployed, state
The date of my last employment was: ____________
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: _____________________________________
Spouse Name: _____________
My Spouse is employed: __________________________
Employer: ______________________________________________
Salary or wages per month: _____________________
Type of work: _______________________________
Contributions from children: _____________________
Contributions from parents: _____________________
Other contributions: _____________________
Checking account: _______________________________
Savings account: _____________________
Certificates of deposit: _______________________________
Real estate (including home): _________________
Motor vehicle: Make ________________,Year _____
Cost _____________, Amount owed $ ___________
Stocks; bonds: _______________________________
Other: _______________________________
Mortgage: _______________________________
Rent: _______________________________
Loans: _______________________________
Other: _______________________________
Spouse Name: _____________
Ages of Minor Children, if any: _______________
Other persons:
Name: _______________________________
Relationship: _______________________________
Date: ___________
Petitioner _______________________________
Action by the Magisterial District Judge: __________
Date:____ Magisterial District Judge:__________
246 Pa. Code r. 206