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IN TIlE COURT OF <XHtOH PLEAS OF V U /.,/ rouHTY. PEHNSnVANIA
L . ~', L DIVISION
COMl'IONWEALTH OF PENNSYLVANIA.
NO, 9rc - 'f 6 (1 '7 C",vJ.. ..:T-<!/V>o--
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Defendant.
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/ / IN FORMA PAUPERIS VERIFIFll STATI2iEHT
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' ;_J-t/.- /' states under the penalties
18
provided
by
Pa.C,S. 94904 (unsworn falsification to authorities) that:
I. I am the defendant in the above action and because of my financial
condition am unable to pay the fees and costs relative to the filing of a notice
of appeal to the Pennsylvania Superior Court,
2. ~Iy responses to the questions below relating to my ability to pay the
fees and costs of prosecuting an appeal are true and correct.
(a) Are you presently employed? Yes ( ) No (:-1,
(1) If the answer is yes, state the amount of
your sa lary or wages per
/./-
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month and give the Ilame and address of your ~mployer.
(2) If the answer is no, state the dilte of your last employment and the
salary and wages per month which you received.
u:::....
(b) Have you recciverl within the piJst twelve months any income from a business,
profession or other form of scl f-cmploYnJPTll, or in lhc form of rent payments,
interests, divl(iends, pensions, dnnuilics, social security benefits, support
payments or olhcr source? Yes ( ) ~o (~\)
If lhc ,H1S....'Pf is 'IPS, d('scribe ench source of income. and state the amount
rcc0iv0l! from CilCh dllrillg the past twelve months.
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(c) Do YOll m,'fl any cash or checking Of savings account? Yes
) No (Y,,)
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IN 'llIE COURT OF C<HtON PLEAS OF r...:C.//?1be/' j..(./I{,f
CIVIL DIVISION
COUNTY, PENNSYLVANIA
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)/cJ/Ukd
I'lninLiff
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VS,
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Defendnnt
NOTICE TO DEFEND AND CLAIM RIGIITS
You have bel~n 'il:el! In (r '!rt. If VOll .....:5~. to L1ctt'nd Ll":!,<lin.':'t th(' cll1ims set
forth in the following pagQ..::;, YOll must take prompt .Jet ion. You an! \.Jarncd that
if you fail to do so, ",' "1.-(' mov rroceui '.,llhout 'lOll "nd " decree of divorce
or nnnldmf:'nt may be l'iltereri 1.::1 i n:"it ::O'J ~!'; the ((l'JrL, \ judgment mny also he
entered against you for dllV r)i.;H~r cL-l:::l (Jr ;;.1 :f~.'f ri'quc.:-iteu in these p<.lpcrs by
the plaintiff, You r.1ay lose '7":';or;f"; Of f:--;:;;'::,r:'; nr c~:'_'r r~ghts impnrt..3nt to you,
including custody or vLsitdtior; 1[ your chl~d;e[:.
\~hen the ground (or divorce is ir.cil,;:;:;l::teS \.'r irretrievable [)reakdO\~'n of
the marriage, you may rC'(]llcst marri3ge counseling. :\ list of marriage counselors
is available in the Office of the ProthonoLJrv at C-u//'lhc' / ~?/Jd
r;OV/J7'
IF YOU DO NOT FILE A CLAnl FOR ALI:lWY. DIVISION OF PROPERTY, LAWYER'S FEES
OF EXPENSES BEFORE A DIVORCE OR ANNl'L'ID:T IS GRAnED. YOU flAY LOSE THE RIGHT
TO CLA HI ANY OF TII [.'1.
YOU SHOULD TAKE THIS PAPER TO YOL'R U\;YER AT O:KE. IF YOlo DO NOT HAVE A
LA\,YER OR CONNOT AFFORD ONE. CO TO OR TELE?HO'iE THE OFFICE SET FORTlI BELOIi TO
FIND OUT \iHERE YOU CAN GET LEGAL lIELP.
c. The Defendant knowin~ly {'lIlt'red into unlawful higamous marriage,
while the former marriage is st.i 11 su!J'.!st ing.
d. Cruel and barharous t.n'iltrTlpnt that C[Uldngt'rcd the life of the
Plaintiff or the health of the injun'd I'lalfltlff.
@ The Plaintiff or ttw Dcferlllant has been convicted
in a court of law to a term of imprisonmellt of more than two years.
and sen tenced
t. The Defendant offered such ind ignities to the innocent and injured
spouse, so as to render thE' SpOllS0'S condition .intolcrnblc and Ij,fc burdensome.
@TO the best of the Plaintiff's knowledge, information and belief, there
has not been any previous action of divorce filed either in this Commonwealth
Dated:
7-/0- Y'u-
A )/#:.~~t:{~V{/
Case Number
or any other state.
9. The Plaintif f does have knowledge of a pending di vorce action filed in
/(/u~(
County, Case
Caption
@ The Plaintiff has been advised of the availability of counseling and
that either party has the right to request that the Court require the parties
to participate in counseling.
WHEREFORE, the Plaintiff request that the court enter a decree of divorce.
Plaintiff Pro 51' --, / _ (7
Institution Number~~ ~~>'~
SCI -Camp Hill
P.O. Box 200
Camp Hill, P^ 17001-0200
-2-
IN TIlE COURT OF COMMON PLEAS OF CV/110t' ,/c./ld
CIVIL DIVISION
COUWfY, PENNSYLVANIA
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Plair.tiff
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NO.
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VS.
Gk/lcA Jk./'/h/1
Defendant
A F F I D A V I T
I. The Plaintiff avers that he is the Plaintiff in the above entitled
divorce action and under 18 Pa.C.S.A. i 4904, relating to unsworn falsification
to authorities, states:
a. There is no issue as to alimony or child support;
b. There is no issue as to equitable distribution to material property
or assets.
Dated:
,1""/0' 96:
jJ/L ~-&~0
Plaintiff Pro ~
P.O. Box 200
Camp Hill, PA 17001-0200
-3-
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IN TIlE COURT OF COMMON PLI,^S OF CU/J1"J< ,/......y)CI:'
CIVIL DIVISION
COUNTY, PENNSYLVANIA
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, PlaintIff
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NO.
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Defendant
PROOF OF SERVICE
r,lJ& ~ druA-/l
, have served a copy of the foregoing
documen t upon the person (s) 1 is t ed be low pursuan t to the Pennsy I vania Ru les
of civil Procedure, by way of United Stales Certified ~Iail, postage prepaid
\..;ith a return receipt.
Complaint in Divorce
Affidavit pursuant to
23 Pa.C.S.A. 9 3301(C)
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Counter Affidavit
pursuant to
23 Pa.C.S.A. 9 3301(c)
PlaintIff's Affidavit
pursuant to
23 Pa.C.S.A. 9 3301(d)
Date mailed:
7~' I'" /)/
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PlainLiff Pro se /)4 z'r-c.:;,')'
rnst i Lilt io"il1TuiiiOcr ->7'/
scr -Camp Hi II .
P.O. !lox "'li,
Camp IIi 1 I , l'A 1700] -0200
-9-