Free Proc - Pennsylvania

MOTION TO PROCEED IN FORMA PAUPERIS

PHILADELPHIA COURT OF COMMON PLEAS

PETITION/MOTION COVER SHEET
ASSIGNED TO JUDGE: FOR COURT USE ONLY ANSWER/RESPONSE DATE:

CONTROL NUMBER:

(RESPONDING PARTIES MUST INCLUDE THIS NUMBER ON ALL FILINGS)

Do not send Judge courtesy copy of Petition/Motion/Answer/Response. Status may be obtained online at http://courts.phila.gov

Month No. Name of Filing Party:

Term,

Year

vs.

(Check one) (Check one)

Plaintiff Movant

Defendant Respondent Yes No No

INDICATE NATURE OF DOCUMENT FILED:
Petition (Attach Rule to Show Cause) Motion Answer to Petition Response to Motion
TYPE OF PETITION/MOTION (see list on reverse side)

Has another petition/motion been decided in this case?

Yes Is another petition/motion pending? If the answer to either question is yes, you must identify the judge(s):
PETITION/MOTION CODE (see list on reverse side)

MOTION TO PROCEED IN FORMA PAUPERIS
ANSWER/RESPONSE FILED TO (Please insert the title of the corresponding petition/motion to which you are responding):

MTIFP

I. CASE PROGRAM Is this case in the (answer all questions): A. COMMERCE PROGRAM Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes No B . DAY FORWARD/MAJOR JURY PROGRAM -- Year Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes No C . NON JURY PROGRAM Date Listed: D. ARBITRATION PROGRAM Arbitration Date: E. ARBITRATION APPEAL PROGRAM Date Listed: F. OTHER PROGRAM: Date Listed: III. OTHER

II. PARTIES (Name, address and telephone number of all counsel of record and unrepresented parties. Attach a stamped addressed envelope for each attorney of record and unrepresented party.)

By filing this document and signing below, the moving party certifies that this motion, petition, answer or response along with all documents filed, will be served upon all counsel and unrepresented parties as required by rules of Court (see PA. R.C.P. 206.6, Note to 208.2(a), and 440). Furthermore, moving party verifies that the answers made herein are true and correct and understands that sanctions may be imposed for inaccurate or incomplete answers. (Attorney Signature/Unrepresented Party) (Date) (Print Name) (Attorney I.D. No.)

The Petition, Motion and Answer or Response, if any, will be forwarded to the Court after the Answer/Response Date. No extension of the Answer/Response Date will be granted even if the parties so stipulate.
30-1061A (Rev. 7/05)

First Judicial District of Pennsylvania
Court of Common Pleas of Philadelphia County Civil Trial Division
___________________________________, pro se
(your name)

___________________________________ ___________________________________
(full address)

___________________________________
(area code and telephone number)

___________________________________ ___________________________________ Plaintiff(s) VS. ___________________________________ ___________________________________ Defendant(s)

: : : : : : : : : : :

_____________________Term, 20_________
(month) (year)

NO._________________________________

In Forma Pauperis Order
AND NOW, this ____________day of ________________________, 20_______ , it is hereby ORDERED AND DECREED that:

1. Petitioner be permitted to proceed without paying the costs of this proceeding or posting a bond. 2. Petitioner be permitted to obtain service of the papers filed without cost. 3. Petitioner be permitted to proceed in forma pauperis as to any additional costs which accrue in the course of this proceeding.
(IFP/REV.10/2000)

Court Term________________20____and No.___________

4. If there is a monetary recovery by judgment or settlement in favor of the party permitted to proceed in forma pauperis, the exonerated fees and costs shall be taxed as costs and paid to the Prothonotary by the party paying the monetary recovery.
5. Petitioner has a continuing obligation to inform the Court of any improvement in party's financial circumstances that will enable the party to pay costs. BY THE COURT:

________________________________________ J.

Page 2 of 11

First Judicial District of Pennsylvania
Court of Common Pleas of Philadelphia County Civil Trial Division
__________________________________, pro se
(your name)

__________________________________ __________________________________
(full address)

__________________________________
(area code and telephone number)

__________________________________

__________________________________ Plaintiff(s) VS. _____________________________ _____________________________ Defendant(s)

: : : : : : : : : : : :

___________________, TERM, 20 ______
(month) (year)

NO. _____________________________

Petition to Proceed In Forma Pauperis and Without Payment of Bond
TO THE HONORABLE, THE JUDGES OF SAID COURT: Petitioner, (your name) _________________________________________, seeks
(please print your name)

leave to proceed in this matter in forma pauperis, and respectfully represents that: 1. I am the (indicate plaintiff or defendant) __________________________ in these proceedings. Court Term__________________20____and No. ________ Page 3 of 11

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. 4. I have the following average monthly expenses for the indicated items: Housing: __________________ Utilities: __________________ (Gas): (Oil): __________________ __________________ Insurance: ____________________

Transportation: __________________ Medical: Loans: Laundry: Child Care: ____________________ ____________________ ____________________ ____________________

(Electric):__________________ (Phone): __________________ Food: __________________

Child Support: ____________________

Clothing: __________________

5. I neither own nor have equity in any assets other than the following (state values in dollars): ____________________________________________________________________ ___________________________________________________________________________ 6. I am unable to pay the costs of these proceedings or to obtain the amount of costs from family or friends.

Page 4 of 11

Court Term__________________20____and No. ________

WHEREFORE, Petitioner prays that he/she be permitted to proceed in this matter in forma pauperis and without the payment of bond. _______________________________________ Petitioner (Print your name) _______________________________________ Petitioner (Sign your name)

Page 5 of 11

First Judicial District of Pennsylvania
Court of Common Pleas of Philadelphia County Civil Trial Division

____________________________________, pro se
(your name)

____________________________________ ____________________________________
(full address)

____________________________________
(area code and telephone number)

_____________________________________ _____________________________________ Plaintiff(s) VS. _____________________________________ _____________________________________ Defendant(s)

: : : : : : : : : : : :

________________________ TERM, 20____
(Month) (Year)

NO. _______________________________

Petitioner's Affidavit Pursuant to PA. R.C.P. 240
COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA : : : SS.

1. I, _________________________________________, am the (Plaintiff) (Defendant)
(circle one)

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.

Page 6 of 11

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: __________________________________________________________________ __________________________________________________________________ Social Security #_____________________________________________________________ (b) EMPLOYMENT If you are presently employed, state: Employer : Address: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Salary/wages Per Month: ______________________________________________________________ Type of Work: ______________________________________________________________ If you are presently unemployed, state: Date of last Employment: __________________________________________________

Salary/Wages Per Month: ______________________________________________________________ Type of Work:______________________________________________________________ (c) OTHER INCOME WITHIN THE PAST TWELVE (12) MONTHS (state as dollar amounts) Business or Profession:_______________________________________________________ Other Self-employment: _____________________________________________________

Page 7 of 11

Interest:___________________________________________________________________ Dividends:_________________________________________________________________ Pension and Annuities:________________________________________________________ Social Security Benefits:_______________________________________________________ Support Payments:___________________________________________________________ Disability Payments:_________________________________________________________ Unemployment Compensation & Supplemental Benefits: _____________________________________________________ Workmans' Compensation: ____________________________________________________ Public Assistance:____________________________________________________________ Other:_____________________________________________________________________ (d) OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT (state as dollar amounts) (Wife) (Husband) (Friend) Name:_______________________________________________ If your (wife) (husband) (friend) is employed, state: Employer: _________________________________________________________________ Salary/Wages Per Month: ______________________________________________________________ Type of Work:______________________________________________________________ Contributions From Children: _____________________________________________________________ Contributions From Parents: ______________________________________________________________ Other Contributions:__________________________________________________________

(e) PROPERTY OWNED (state as dollar amounts) Cash:______________________________________________________________________

Page 8 of 11

Checking Account:___________________________________________________________ Savings Account:____________________________________________________________ Certificates of Deposit:________________________________________________________ Real Estate (Including Home): ___________________________________________________________ Motor Vehicle: Make _______________________________ Year __________________ Cost $_________________________________ ____________________ Amount Owed Z

Stocks & Bonds: ____________________________________________________________ Other: _____________________________________________________________________ _____________________________________________________________________

(f) DEBTS AND OBLIGATIONS (state as dollar amounts) Mortgage: __________________________________________________________________ Rent: Loans: Other: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

(g) PERSONS DEPENDENT UPON YOU FOR SUPPORT (Wife) (Husband) Name: ______________________________________________________ Children, if any: _________________________________Age _______________________ _________________________________Age _______________________ _________________________________Age _______________________ _________________________________Age _______________________ Other Persons: Name:_________________________________________________________________ Page 9 of 11

Relationship: __________________________________________________________

4. I understand that I have a continuing obligation to inform the Court of improvement in my financial circumstances which would permit me to pay the costs incurred herein. 5. 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.

Dated: ____________________

__________________________________________ Petitioner (Print your name)

__________________________________________ Petitioner (Sign your name)

Sworn to and subscribed before me this ______ day of ______________,20______. __________________________________ Notary Public

Page 10 of 11

Certificate of Service
I hereby certify that I have served a copy of this petition upon all other parties or their attorney of record by: Please check:

Regular First Class Mail Certified Mail Other

Name of Petitioner

(Print Name)

Signature of Petitioner

(Sign your name)

Dated: ________________________

Page 11 of 11

Instructions for completing Petition to Proceed In Forma Pauperis
1. All blanks and all questions MUST be filled in or answered. Dollar amounts MUST be clearly stated where requested. 2. A copy of your latest Pennsylvania tax or federal tax return should be attached. 3. Service of a copy of this petition MUST be made on the opposing party or opposing party's attorney. 4. Please attach a self-addressed, stamped envelope for yourself and an addressed, stamped envelope for each opposing party or opposing party's attorney. 5. Petitioner is required to have the enclosed Affidavit notarized by a licensed Notary Public. 6. Your petition may be dismissed or denied for failure to properly complete all information.
Definition of Terms: Affidavit: A voluntary declaration of facts written down and sworn to by the declarant before an officer authorized to administer oaths. Defendant: A person who is sued in a civil or criminal proceeding. In Forma Pauperis: [Latin "in the manner of a pauper"] To proceed in the manner of an indigent who is permitted to disregard filing fees and court costs. Petitioner: A party who presents a petition to a court or other official body. Plaintiff: The party who brings a civil suit in a court of law against another person or entity.