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Instructions for:
Form 2
Petition to Proceed In Forma Pauperis
Form 2 - Petition to Proceed In Forma Pauperis
The following numbers on these instructions correspond with the numbers in the arrowboxes
beginning on page 1 on the In Forma Pauperis form. Use the form with the arrowboxes to guide
you through filling out the blank form.
On Page 1 of 6, by arrowbox 1 write in the county in which you are filing your divorce.
See "Where do I File?" in the Introduction for more information about what county you
should file in.
On page 1, by arrowbox 2 write your name. Write your name exactly as you wrote it on
the other forms.
On page 1, by arrowbox 3 write your spouse's name. Write your spouse's name exactly as
you wrote it on the other forms.
Do not write anything by arrowbox 4. The Prothonotary's Office will write the docket
number for your divorce by arrowbox 4 at the time of filing.
o not write anything else on Page 1 as it will be completed by the Court.
Complete the form by providing the information requested on pages 2 through 5. Remember to
answer each question.
5.
On page 2, by arrowbox 5 write in the county in which you are filing your divorce.
Arrowbox 1 (page 1) and Arrowbox 5 should be the same.
On page 2, by arrowbox 6 write your name. Write your name exactly as you wrote it
on page 1 of this form.
On page 2, by arrowbox 7 write your spouse's name. Write your spouse's name exactly as
you wrote it on page 1 of this form.
On page 2, by arrowbox 8 do not write anything.
ILL IN ALL PERTINENT INFORMATION ON PAGES 2 THROUGH 5.
On page 6, by arrowbox 9 write the date on which you are completing this form.
On page 6, by arrowbox 10, after carefully reading the statements, sign your name on the
form.
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IN THE COURT OF COMMON PLEAS OF
_____________________________COUNTY, PENNSYLVANIA
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2
CIVIL ACTION-LAW
_______________________________,
PLAINTIFF
vs.
_______________________________,
DEFENDANT
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Case No. _______________
ORDER RE: MOTION TO PROCEED IN FORMA PAUPERIS
AND NOW, this _________ day of ______________________, 20____, the Petitioner's
Motion to Proceed In Forma Pauperis is granted as to the filing fees and costs.
Y THE COURT,
J.
____________________________
B
_
Form 2
Page 1 of 6
a.) My Name is: _____________________________________________
My Address is: ____________________________________________
________________________________________________
b.) Employment:
If you are presently employed, state your:
Employer: ________________________________________________
IN THE COURT OF COMMON PLEAS OF
_____________________________COUNTY, PENNSYLVANIA
5
6
CIVIL ACTION-LAW
_______________________________,
PLAINTIFF
vs.
_______________________________,
DEFENDANT
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Case No. _______________
PETITION TO PROCEED IN FORMA PAUPERIS & AFFIDAVIT
1.
I am the petitioner in the above matter and because of my financial condition am unable
to pay the fees and costs of prosecuting or defending this action or proceeding.
2.
I am unable to obtain funds from anyone, including my family and associates, to pay the
3.
I represent that the information below relating to my ability to pay the fees and costs is
costs of litigation.
true and correct:
Form 2
Page 2 of 6
Employer’s 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: _____________________________________________
c.) Please list any other income received within the past twelve months:
(Write the gross amount (before taxes) per month that you received and the months you
received this income.)
Business or profession: ___________________________________
Other self-employment: __________________________________
Interest: ______________________________________________
Dividends: _____________________________________________
Pension and annuities: ___________________________________
Social security benefits: __________________________________
Support payments: ______________________________________
Disability payments: _____________________________________
Unemployment compensation and/or supplemental benefits: ________
______________________________________________________
Workers’ Compensation: ________________________________
Form 2
Page 3 of 6
Public assistance: _______________________________________
Other: ________________________________________________
d.) Other contributions to household support:
(Write the gross amount (before taxes) per month that you received and the months you
received this income.)
(Wife) (Husband) Name: _________________________________
If your (wife) (husband) is employed, please state
Employer: _____________________________________________
Salary or wages per month: ________________________________
Type of work: __________________________________________
Contributions from children: _______________________________
Contributions from parents: _______________________________
Other contributions: _____________________________________
e.) Property owned:
Cash: ________________________________________________
Checking Account: ______________________________________
Savings Account: _______________________________________
Certificates of deposit: ___________________________________
Real estate (including home): ______________________________
Motor Vehicle: Make__________________, Year____________,
Cost: ___________ Amount Owed: ____________
Stocks and bonds: __________________________________________
Form 2
Page 4 of 6
Other: ________________________________________________
______________________________________________________
f.) Debts and obligations:
Mortgage: _____________________________________________
Rent: _________________________________________________
Loans: ________________________________________________
Other: ________________________________________________
______________________________________________________
(Write all of your regular monthly bills, phone, utilities, cable, insurance, etc.)
g.) Persons dependent upon you for support:
(Wife/Husband) Name: ___________________________________
Children, if any:
Name: ____________________________ Age:_________
____________________________ _________
____________________________ _________
Other persons:
Name: ____________________________________
Relationship: _______________________________
4.
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.
Form 2
Page 5 of 6
5.
I verify that the statements made in this affidavit are true and correct. I understand
that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904,
relating to unsworn falsification to authorities.
9
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ate: _________________________
____________________________________
PETITIONER
D
Form 2
Page 6 of 6
ORDER RE: MOTION TO PROCEED IN FORMA PAUPERIS
AND NOW, this _________ day of ______________________, 20____, the Petitioner's Motion to
Proceed In Forma Pauperis is granted as to the filing fees and costs.
_____________________________COUNTY, PENNSYLVANIA
IN THE COURT OF COMMON PLEAS OF
_______________________________,
PLAINTIFF
vs.
_______________________________,
DEFENDANT
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CIVIL ACTION-LAW
Case No. _______________
Y THE COURT,
J.
____________________________
B
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_____________________________COUNTY, PENNSYLVANIA
IN THE COURT OF COMMON PLEAS OF
_______________________________,
PLAINTIFF
_______________________________,
DEFENDANT
vs.
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CIVIL ACTION-LAW
Case No. _______________
PETITION TO PROCEED IN FORMA PAUPERIS & AFFIDAVIT
1.
I am the petitioner in the above matter and because of my financial condition am unable (cid:87)o pay
the fees and costs of prosecuting or defending this action or proceeding.
2.
I am unable to obtain funds from anyone, including my family and associates, to pay the(cid:3)(cid:70)osts of
3.
I represent that the information below relating to my ability to pay the fees and costs is(cid:3)(cid:87)rue
litigation.
and correct:
a.) My Name is: _____________________________________________
My Address is: ____________________________________________
________________________________________________
b.) Employment:
If you are presently employed, state your:
Employer: ________________________________________________
Employer’s 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: _____________________________________________
c.) Please list any other income received within the past twelve months:
(Write the gross amount (before taxes) per month that you received and the months
you received this income.)
Business or profession: ___________________________________
Other self-employment: __________________________________
Interest: ______________________________________________
Dividends: _____________________________________________
Pension and annuities: ___________________________________
Social security benefits: __________________________________
Support payments: ______________________________________
Disability payments: _____________________________________
Unemployment compensation and/or supplemental benefits:
______________________________________________________
Workers’ Compensation: ________________________________
Public assistance: _______________________________________
Other: ________________________________________________
d.) Other contributions to household support:
(Write the gross amount (before taxes) per month that you received and the months
you received this income.)
(Wife) (Husband) Name: _________________________________
If your (wife) (husband) is employed, please state
Employer: _____________________________________________
Salary or wages per month: ________________________________
Type of work: __________________________________________
Contributions from children: _______________________________
Contributions from parents: _______________________________
Other contributions: _____________________________________
e.) Property owned:
Cash: ________________________________________________
Checking Account: ______________________________________
Savings Account: _______________________________________
Certificates of deposit: ___________________________________
Real estate (including home): ______________________________
Motor Vehicle: Make__________________, Year____________,
Cost: ___________ Amount Owed: ____________
Stocks and bonds: __________________________________________
Other: ________________________________________________
______________________________________________________
f.) Debts and obligations:
Mortgage: _____________________________________________
Rent: _________________________________________________
Loans: ________________________________________________
Other: ________________________________________________
______________________________________________________
(Write all of your regular monthly bills, phone, utilities, cable, insurance, etc.)
g.) Persons dependent upon you for support:
(Wife/Husband) Name: ___________________________________
Children, if any:
Name: ____________________________ Age:_________
____________________________ _________
____________________________ _________
Other persons:
Name: ____________________________________
Relationship: _______________________________
4.
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.
5.
I verify that the statements made in this affidavit are true and correct. I understand that false
statements herein are made subject to the penalties of 18 (cid:51)a.C.S. § 4904, (cid:85)elating
to unsworn falsification to authorities.
ate: _________________________
____________________________________
PETITIONER
D
