(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: ______________________________________
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: ___________________________
Name:
____________
Age:
____________
_________________________
____________
_________________________
____________
Other Persons:Name: ______________________________________
Relationships:
______________________________________
____________
…
____________
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 § 240