AUTHORIZATION OF 
REPRESENTATIVE 
OTORIZASYON POU REPREZANTAN 
 

 

___________________________________ 
V. / Kont 
 

___________________________________ 
 

Docket No./Nimewo Lis Dosye.: 

Case Filed/Ka a Ranpli: 

   

 

 

 

 

COMMONWEALTH OF PENNSYLVANIA 
COUNTY OF 

KOMINOTE PENNSYLVANIA  

KONTE 
 

Mag. Dist. No: 
Nimewo Distri Majistral: 
MDJ Name: 
Non Jij Distri Majistral la: 

ddress: 

Adrès: 

elephone: 

Telefòn: 

  A

    T

 

 

PURSUANT TO PA. R.C.P.M.D.J. NO. 207(B): 
  Individual: 

SELON PA. R.C.P.M.D.J. NIMEWO 207(B): 
  Moun nan: 

I designate ___________________________________ 
to act as the authorized representative in the above-
captioned matter. 

Mwen nome __________________________________ 
pou aji kòm reprezantan otorize a nan afè ki endike 
anwo a. 

Date/Dat:___________________ 

Name (Print)/Non (Ak lèt detache):____________________________________ 
Signature/Siyati:____________________________________ 

  Partnership, Corporation or Similar Entity: 

  Patenarya, Antrepriz oswa Menm Antite: 

I designate __________________________________ 
to act as the authorized representative of 
_________________________ in the above-captioned 
matter. 
I further certify that I have the authority to execute this 
form on behalf of the party and that I am: (check one) 
  the individual or sole proprietor that is the party;  
  an officer of the corporation that is the party; 
  a partner of the general partnership that is the party; 
  a general partner of the limited partnership that is 

Mwen nome __________________________________ 
pou aji kòm reprezantan otorize 
_______________________ nan afè ki endike anwo a. 

Anplis, mwen sètifye mwen gen otorite pou m egzekite 
fòm sa a nan non pati a epi mwen se: (tcheke youn) 
  moun oswa sèl pwopriyetè ki se pati a;  
  yon ajan nan antrepriz la ki se pati a; 
  yon patnè nan patenarya jeneral la ki se pati a; 
  yon patnè jeneral nan patenarya limite a ki se  

  a manager of the limited liability company that is the 

  yon manadjè konpayi responsablite limite a ki se 

pati a  

pati a; 

the party  

party; 

  an officer of the board of governors of the 
professional association that is the party;  
  a trustee of the business trust that is the party; 
 
Date/Dat:___________________ 

  yon ajan nan konsèy gouvènè a nan asosyasyon 

pwofesyonèl la ki se pati a;  

  yon fidisyè nan fidisi komèsyal la ki se pati a; 
 

Name (Print)/Non (Ak lèt detache):____________________________________ 
Signature/Siyati:____________________________________ 

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ame/Non:  _____________________________________________________________________________________ 
Address/Adrès:  __________________________________________________________________________________ 
City, State, Zip/Vil, Eta, Kòd Postal:  __________________________________________________________________ 
Phone/Telefòn:  ___________________________________________________________________________________ 

I, ______________________________________, do 
hereby verify, to the best of my knowledge, information and 
belief, that I have personal knowledge of the facts and 
circumstances of the above-captioned matter. 
I certify that this filing complies with the provisions of the 
Case Records Public Access Policy of the Unified Judicial 
System of Pennsylvania that require filing confidential 
information and documents differently than non-confidential 
information and documents. 

Mwen, ______________________________________, 
verifye nan dokiman sa a, selon pi bon konesans, 
enfòmasyon, ak kwayans mwen, mwen genyen konesans 
pèsonèl sou fè ak sikonstans afè ki endike pi wo a. 
Mwen sètifye demann mwen depoze sa a konfòme ak 
dispozisyon Politik Aksè Piblik nan Dosye Ka Sistèm 
Jidisyè Inifye Pennsylvania a ki egzije yo depoze 
enfòmasyon konfidansyèl yon fason diferan ak fason yo 
depoze dokiman ak enfòmasyon ki pa konfidansyèl yo. 

Non Reprezantan Otorize a (Ak Lèt Detache): _____________________________________________________ 
Signature/Siyati: ______________________________________________________ 

ame of Authorized Representative (Print)/ 

  N

uthorized Representative Contact Information: 

nfòmasyon Kontak Reprezantan Otorize a: 

  A

  N

 

 

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