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Here is the text we could read:

Commonwealth of Pennsylvania 
Court of Common Pleas County 
of ________________
_______ Judicial District

Address:

Telephone:

County Clerk of Courts

Docket No:

Motion to Proceed In Forma Pauperis

Commonwealth of Pennsylvania
v.

I, ______________________________ , residing at _____________________________________________________, 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:

1.

2.

3.

I am the defendant in the above-captioned 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:

Type of Work:

Other Income Received Within The Past Twelve Months

Employment Information

Salary or Wages per Month: 

Type of Work:

If you are presently employed, state employer:

Name:

Address:

If you are presently unemployed, state:

The date of my last employment was: 

Salary or Wages per Month: 

If spouse is presently employed, state employer:

Spouse's name:

Name:

Address:

Salary or Wages per Month: 

Type of Work:

If spouse is presently unemployed, state:

The date of spouse's last employment was: 

Salary or Wages per Month: 

Type of Work:

Contributions from Children:

Contributions from Parents:

Other Contributions:

CPCMS 2046

1

Commonwealth of Pennsylvania 
v.

Motion to Proceed In Forma Pauperis

Do you own a home or other real property? If so, please provide for each:

Do you own an automobile? If so, please provide for each:

Docket No: 

Assets/Property Owned

Certificates of Deposit:

Stocks and Bonds:

Other:

Debts and Obligations

Persons Dependent Upon Me For Support

Amount Owed: 

Year:

Amount Owed: 

Loans: 

Other: 

Relationship:

Relationship:

Cash:

Checking Account:

Savings Account:

Real Estate:

Address:

Assessed Value: 

Motor Vehicle: 

Make:

Model:

Cost: 

Rent:

Mortgages: 

(Other than those listed above)

Spouse's Name:

Ages of Minor Children, if any: 

Other Persons (non-minor)

Name:

Name:

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 Public Access Policy of the Unified Judicial System of 
Pennsylvania: Case Records of the Appellate and Trial Courts that require filing confidential information and 
documents differently than non-confidential information and documents.

Signature of Petitioner

Date

CPCMS 2046

2

(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): 65
Average fields per page: 32
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

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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.

judicial_district was JudicialDistrict (0.53 conf)
nameof_present_employer was NameofPresentEmployer (0.50 conf)
addressof_present_employer was AddressofPresentEmployer (0.50 conf)
typeof_work_present_employer was TypeofWorkPresentEmployer (0.40 conf)
salaryfrom_present_employer was SalaryfromPresentEmployer (0.50 conf)
dateof_last_emplyment was DateofLastEmplyment (0.34 conf)
salary_last_employment was SalaryLastEmployment (0.37 conf)
typeof_work_last_employment was TypeofWorkLastEmployment (0.34 conf)
spouse_name was SpouseName (0.44 conf)
spouses_employer was SpousesEmployer (0.40 conf)
spouses_employer_address was SpousesEmployerAddress (0.37 conf)
spouses_salary was SpousesSalary (0.42 conf)
spouses_typeof_work was SpousesTypeofWork (0.45 conf)
spouses_last_employment was SpousesLastEmployment (0.33 conf)
spouses_salary_last_employer was SpousesSalaryLastEmployer (0.36 conf)
spouses_last_employment_work was SpousesLastEmploymentTypeofWork (0.37 conf)
contributionsfrom_children was ContributionsfromChildren (0.34 conf)
contributionsfrom_parents was ContributionsfromParents (0.37 conf)
contributions was OtherContributions (0.28 conf)
address__1 was Address1 (0.35 conf)
address__2 was Address2 (0.35 conf)
address__3 was Address3 (0.35 conf)
county_court_city was CountyCourtCity (0.42 conf)
pa was PA (0.39 conf)
county_court_zip was CountyCourtZip (0.38 conf)
county_court_phone_number was CountyCourtPhoneNumber (0.45 conf)
defendant_address was DefendantAddress (0.40 conf)
certificationof_compliance was CertificationofCompliance (0.41 conf)
cash was Cash (0.45 conf)
certificatesof_deposits was CertificatesofDeposits (0.38 conf)
stocksand_bonds was StocksandBonds (0.42 conf)
savings_account was SavingsAccount (0.42 conf)
assests was OtherAssests (0.39 conf)
addressof_property was AddressofProperty (0.47 conf)
assessed_value was AssessedValue (0.35 conf)
makeof_vehicle was MakeofVehicle (0.30 conf)
modelof_vehicle was ModelofVehicle (0.30 conf)
yearof_vehicle was YearofVehicle (0.30 conf)
costof_vehicle was CostofVehicle (0.30 conf)
rent was Rent (0.43 conf)
loans was Loans (0.43 conf)
mortgages was Mortgages (0.46 conf)
obligations was OtherObligations (0.40 conf)
dependent_spouse was DependentSpouse (0.39 conf)
realtionship was Realtionship (0.35 conf)
dependents_non_minor__1 was DependentsNonMinor2 (0.46 conf)
relationship was Relationship2 (0.35 conf)
signature_date was Date (1.00 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)
checking_account was CheckingAccount (0.37 conf)
dependents_non_minor__2 was DependentsNonMinor (0.52 conf)
petitioner_signature was PetitionerSignature (0.50 conf)
amount_owed_real_estate was AmountOwedRealEstate (0.50 conf)
amount_owed_automobile was AmountOwedAutomobile (0.47 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