IN THE COURT OF COMMON PLEAS OF - Beaver County

IN THE COURT OF COMMON PLEAS OFBEAVER COUNTY, PENNSYLVANIA___________________________Plaintiff,Vs.No. ______________________________________Defendant,PETITION TO PROCEED IN FORMA PAUPERISTO THE HONORABLE, THE JUDGES OF THE SAID COURT:Petitioner respectfully represents that:1. Petitioner ____________________________________ is the plaintiffin the above captioned action.2. Petitioner’s Social Security number is _______________________3. Petitioner’s address is ______________________________________________________________________________________________4. Petitioner’s income and expense information is fully and accuratelyset forth in the attached affidavit.5. Petitioner’s Date of Birth: __________________________________(Month, Day, Year)WHEREFORE, Petitioner respectfully requests Your HonorableCourt to enter an Order, granting leave to proceed in forma pauperis in theabove captioned action.Respectfully submitted,______________________________Petitioner

IN THE COURT OF COMMON PLEASBEAVER COUNTY, PENNSYLVANIA________________________________________Vs.No.________________________________________Affidavit in Support of Petition to Proceed In Forma Pauperis1. I am the (plaintiff) (defendant) in the above matter andbecause of my financial condition am unable to pay the feesand costs of prosecuting or defending the action or proceeding.2. I am unable to obtain funds from anyone, including my familyand associates, to pay the costs of litigation.3. I represent that the information below relating to my ability topay the fees and costs is true and correct:(a) Name: _____________________________________________Address: ______________________________________________________________________________________________Social Security Number: ________________________________(b) EmploymentIf you are presently employed, stateEmployer: _________________________________________Address: ____________________________________________________________________________________________

Salary or wages per month: ___________________________Type of Work: ____________________________________If you are presently unemployed, stateDate of last employment ______________________________Salary of wages per month _________________________Type of Work: ______________________________________(c) Other income within the past twelve monthsBusiness or profession: _______________________________Other self-employment: ______________________________Interest: ___________________________________________Dividends: _________________________________________Pension and annuities: _______________________________Social Security Benefits: ______________________________Support Payments: __________________________________Disability payments: _________________________________Unemployment compensation and supplemental benefits:______________________________________________________________________________________________________Workman’s compensation: _________________________Public Assistance: ______________________________Other: ____________________________________________________________________________________________(d) Other contributions to household support(Wife) (Husband) Name: _________________________If your (wife) (husband) is employed, stateEmployer: _________________________________________Salary or Wages per month: _________________________Type of work: ____________________________________Contributions from children: _________________________Contributions from parents: _________________________Other Contributions: ______________________________(e) Property ownedCash: _____________________________________________Checking account: ______________________________Savings account: ___________________________________Certificates of deposit: ______________________________Real estate (including home): _________________________

IN THE COURT OF COMMON PLEAS OFBEAVER COUNTY, PENNSYLVANIA___________________________Plaintiff,Vs.No. ______________________________________Defendant,ORDER TO WAIVE FILING COSTSAND NOW, this _______ day of _______________, 200__,upon consideration of the attached Petition to Proceed in Forma Pauperis, itis hereby ordered that the filing costs be waived.BY THE COURT______________________________Judge