The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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Here is the text we could read:

COMMONWEALTH OF PENNSYLVANIA
COUNTY OF

IN FORMA PAUPERIS AFFIDAVIT
PETITION

_________________________
vs.

_________________________

Docket No:
Case Filed:

STATEMENT OF THE PETITIONER

I hereby request that this Court permit me to proceed in forma pauperis (without payment of the filing fee). In support of this I state the
following:

I am the plaintiff in the above matter and because of my financial condition am unable to pay the fee for filing this action.

I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation.

I represent that the information below relating to my ability to pay the fees and costs, is true and correct.

NAME AND ADDRESS

If you are presently employed, state employer:

NAME

ADDRESS 1

ADDRESS 2

CITY

STATE

SALARY OR WAGES PER MONTH

ZIP

FREE INTERPRETER
www.pacourts.us/language-rights

$$$$$

INTEREST

DIVIDENDS

SUPPORT PAYMENTS

DISABILITY PAYMENTS

PUBLIC ASSISTANCE

TYPE OF WORK

If you are presently unemployed, state:

THE DATE OF MY LAST EMPLOYMENT WAS

SALARY OR WAGES PER MONTH

TYPE OF WORK

OTHER INCOME RECEIVED WITHIN THE PAST TWELVE MONTHS

UNEMPLOYMENT COMPENSATION AND SUPPLEMENTAL BENEFITS

$ $ $ $ $

BUSINESS OR PROFESSION

OTHER SELF-EMPLOYMENT

PENSION AND ANNUITIES

SOCIAL SECURITY BENEFITS

WORKERS' COMPENSATION

OTHER

AOPC 622A

Mag. Dist. No:
MDJ Name:

Address:

Telephone:

NAME

ADDRESS 1

ADDRESS 2

CITY

STATE

ZIP

Docket No.:

$ $

MY SPOUSE IS EMPLOYED

SALARY OR WAGES PER MONTH

CHECKING ACCOUNT

CERTIFICATES OF DEPOSIT

YEAR

AMOUNT OWED

OTHER

$ $

RENT

OTHER

RELATIONSHIP

$$$

$ $

OTHER CONTRIBUTIONS

PROPERTY OWNED

CASH

SAVINGS ACCOUNT

REAL ESTATE (INCLUDING HOME)

MOTOR VEHICLE MAKE

COST

STOCKS; BONDS

SPOUSE'S NAME

SPOUSE'S EMPLOYER

TYPE OF WORK

DEBTS AND OBLIGATIONS

$ $

MORTGAGE

LOANS

SPOUSE NAME

AGES OF MINOR CHILDREN, IF ANY

OTHER PERSONS (NON-MINOR)

NAME

PERSONS DEPENDENT UPON ME FOR SUPPORT

OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT

CONTRIBUTIONS FROM CHILDREN

CONTRIBUTIONS FROM PARENTS

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.
I verify that the statements made in this petition are true and correct. I understand that false statements herein are made
subject to penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities.
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.

Date:__________________________

________________________________________________________________

Signature of Petitioner

Action by the Magisterial District Judge: ___________________________________________________________________________

Date

Magisterial District Judge

SEAL

AOPC 622A

FREE INTERPRETER
www.pacourts.us/language-rights

(Untitled)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 2
Fields(s): 93
Average fields per page: 46
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

county was County (0.54 conf)
md_j_number was MDJ Number (0.45 conf)
md_j_name was MDJ Name (0.40 conf)
md_j_phone was MDJ Phone (0.39 conf)
defendant was Defendant (1.00 conf)
date_filed was Date Filed (0.44 conf)
check_box__1 was Check Box1 (0.52 conf)
check_box__2 was Check Box2 (0.37 conf)
check_box__3 was Check Box3 (0.37 conf)
plaintiff was Plaintiff1 (0.35 conf)
name was Name1 (0.35 conf)
address__1 was Address3 (0.35 conf)
address__2 was Address4 (0.35 conf)
employer_name was Employer Name1 (0.39 conf)
employer_address__1 was Employer Address1 (0.39 conf)
employer_address__2 was Employer Address2 (0.39 conf)
employer_address__3 was Employer Address3 (0.39 conf)
address__3 was Address5 (0.35 conf)
unemployed__1 was Unemployed 2 (0.40 conf)
unemployed__2 was Unemployed 3 (0.40 conf)
employer_salary was Employer Salary (0.42 conf)
income__1 was Other Income 10 (0.42 conf)
income__2 was Other Income 12 (0.42 conf)
unemployed__3 was Unemployed 1 (0.40 conf)
income__3 was Other Income 11 (0.42 conf)
income__4 was Other Income 1 (0.42 conf)
income__5 was Other Income 3 (0.42 conf)
income__6 was Other Income 2 (0.42 conf)
income__7 was Other Income 4 (0.42 conf)
income__8 was Other Income 5 (0.42 conf)
income__9 was Other Income 6 (0.42 conf)
income__10 was Other Income 7 (0.42 conf)
income__11 was Other Income 8 (0.42 conf)
income__12 was Other Income 9 (0.42 conf)
employer_address__4 was Employer Address4 (0.39 conf)
employer_address__5 was Employer Address5 (0.39 conf)
address__4 was Address1 (0.35 conf)
court_address__1 was CourtAddress1 (0.45 conf)
address__5 was Address2 (0.35 conf)
court_address__2 was CourtAddress2 (0.45 conf)
county_court_city was CountyCourtCity (0.42 conf)
pa was PA (0.39 conf)
county_court_zip was CountyCourtZip (0.38 conf)
spouse__1 was Spouse 1 (0.39 conf)
spouse__2 was Spouse 2 (0.39 conf)
check_box__4 was Check Box4 (0.37 conf)
spouse__3 was Spouse 3 (0.39 conf)
spouse__4 was Spouse 5 (0.39 conf)
spouse__5 was Spouse 6 (0.39 conf)
spouse__6 was Spouse 7 (0.39 conf)
property__1 was Property 2 (0.39 conf)
property__2 was Property 4 (0.39 conf)
property__3 was Property 5 (0.39 conf)
property__4 was Property 6 (0.39 conf)
property__5 was Property 7 (0.39 conf)
property__6 was Property 8 (0.39 conf)
property__7 was Property 9 (0.39 conf)
property__8 was Property 10 (0.39 conf)
property__9 was Property 11 (0.39 conf)
property__10 was Property 1 (0.39 conf)
property__11 was Property 3 (0.39 conf)
debt__1 was Debt 1 (0.48 conf)
debt__2 was Debt 2 (0.48 conf)
debt__3 was Debt 3 (0.48 conf)
debt__4 was Debt 4 (0.48 conf)
spouse__7 was Spouse 4 (0.39 conf)
check_box__5 was Check Box5 (0.37 conf)
check_box__6 was Check Box6 (0.37 conf)
check_box__7 was Check Box7 (0.37 conf)
check_box__8 was Check Box8 (0.37 conf)
check_box__9 was Check Box9 (0.37 conf)
petitioner_date was PetitionerDate (0.41 conf)
signatureof_mdj was SignatureofMDJ (0.40 conf)
date_signedby_mdj was DateSignedbyMDJ (0.38 conf)
action_takenby_mdj was ActionTakenbyMDJ (0.42 conf)
petitioners_signature was PetitionersSignature1 (0.46 conf)
dependent__1 was Dependent 7 (0.44 conf)
dependent__2 was Dependent 5 (0.44 conf)
dependent__3 was Dependent 6 (0.44 conf)
dependent__4 was Dependent 8 (0.44 conf)
dependent__5 was Dependent 2 (0.44 conf)
agesof_dependent_children__1 was AgesofDependentChildren1 (0.38 conf)
agesof_dependent_children__2 was AgesofDependentChildren2 (0.38 conf)
agesof_dependent_children__3 was AgesofDependentChildren3 (0.38 conf)
agesof_dependent_children__4 was AgesofDependentChildren4 (0.38 conf)
agesof_dependent_children__5 was AgesofDependentChildren5 (0.38 conf)
agesof_dependent_children__6 was AgesofDependentChildren6 (0.38 conf)
agesof_dependent_children__7 was AgesofDependentChildren7 (0.38 conf)
agesof_dependent_children__8 was AgesofDependentChildren8 (0.38 conf)
agesof_dependent_children__9 was AgesofDependentChildren9 (0.38 conf)
agesof_dependent_children__10 was AgesofDependentChildren10 (0.38 conf)
agesof_dependent_children__11 was AgesofDependentChildren11 (0.38 conf)
agesof_dependent_children__12 was AgesofDependentChildren12 (0.38 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02