(Caption)

1. I am the (plaintiff) (defendant) in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding.

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

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

(a) Name:________________________________

Address:_________________________________

________________________________________

(b) Employment

If you are presently employed, state

Employer:_______________________________

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) Other income within the past twelve months Business or profession:

Other self-employment:_______________

Interest:______________

Dividends:_____________

Pension and annuities:_______________

Social security benefits:________________

Support payments:__________________

Disability payments:__________________

Unemployment compensation and supplemental benefits:_______________________

Workers’ compensation:_________________________

Public assistance:_______________________

Other: Rule 240 200-47 (390061) No. 521 Apr. 18 (d) Other contributions to household support:

(Wife) (Husband) Name:_________________________

If your (wife) (husband) is employed, 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:______________

(g) Persons dependent upon you for support

(Wife) (Husband) Name:____________________

Children, if any:__________________

Initials:__________

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 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

Date:__________________ Petitioner______________________________