HomeMy WebLinkAbout09-8337IN THE COURT OF COMMON PLEAS
Cumbo'-Ogd Cwn+Y PENNSYLVANIA
Afia k QQCSlizr ,
PLAINTIFF A
IN CUSTODY S'33 -7
VS.
N rni??Q?, NO: OF
S?f.?a nr k 11, , ,t'
DEFENDANT
PRAEaPE TO PROCEED IN FORMA PAUPERIS
I, J awn ?c , I?.ESS? I ?,v , am unable to pay the costs of litigation.
My affidavit showing inability to pay the costs of litigation is attached hereto.
aintiff
IN THE COURT OF COMMON PLEAS
(_ V (n15Q (-I% nVJ (. oUt1+Y PENNSYLVANIA
3?y?& I I( ?Qrg- Qf
PLAINTIFF
IN CUSTODY
VS.
SNO OF
DEFENDANT
1. I am the Plaintiff 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
ASC
and costs is tr?e and correct:
(a) Name:
Addres
Social Security Number: 11 - 2 0- i 2.0
(b) Employment
If you are pre
Employer:
Address:
state
Salary or Wages per month:
Type of Work:
If you are presently unemployed s ate
Date of last employment: ??I V
Salary or wages per month: , ?-
Type of work: i0 a V Q, ( ?i
(c) Other income within the past twelve months
Business or profession: . L C ,
Other self-employment:
Interest:
(g) Persons dependent upon you for support
(Wife) (I lusba. M5 Name, -
Children, if any:
Name: _,? ¢?C??.f 2??vsle? Cz'afe
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.A. §4904, relating to unsworn falsification to authorities.
Date: ,D-- C-)- - a I
itioner
AND NOW, this _ day of , 20 , the Praecipe
to Proceed in Forma Pauperis is
BY THE COURT
I
4
t
E"f' - ,
-VT i,r
H09 DEC -2 Pil 3: 31
IN THE COURT OF COMMON PLEAS
CJ'M()Q('Ian CC?,'"t ty PENNSYLVANIA
?A"a( k V's<AO-c
PLAINTIFF CIVIL ACTION-(CUSTODY)
(PARTIAL CUSTODY)(VISITATION)
VS.
J ?C?<?(1? ? i ?LQr NO. C.D. OF
4
DEFENDANT N o, D 3 3-7 -f e-"w
COMPLAINT FOR ,r c? I C
` (custody / partial cust y / visitation)
1. The Plaintiff is _? AS01) le, I ns lec , residing at
(Plaintiffs name)
340 Pa-Vii S ftn RO JdA?,fi\X M 116-11- I?oh?n , (711)460, 6410
(Street) (City) ` (State) (Zip Code) (Cou ) (Telephone)
?j i' t I 2r , residing at
2. The Defendant is (
(Defendant's name)
.1at E. MN S1 AQft ho n' csb';' ?A 1? GSS c? ?? lc?? 1 ???a- 1, -4410
(Street) (City) (State) Zip Code) (County) (Telephone)
3. Plaintiff seeks _ pgri-.a I C -i-Ad of the following child(ren):
(custody / partial custody / visitation)
Name ?aP a en R hsi en ?.? Date of Birth
,?y? Qs? ss?ar cis ,5- 3 43
The child(ren) ( *as/were ?was not/were not ) born out of wedlock.
The child(ren) is/are presently in the custody of 51t 4,4 n 4 NIV
(name)
who resides at M`i'n 5? A? i?19J???111i?S??(c? ?`1 ?7?J?S
(Street) (City) (State) (Zip Code)
During the past five years, the child(ren) has/have resided with the following
persons and at the following addresses:
(Names) (Addresses)
aaS E Matt/
??N ?? Sly. + l??v? ?e?nl 3yo/ ?cd
,t?7echdn ?i
I SSW LC-s VLO1*44?-dL
J aSb1V k cssL t s+eKani? f ?w n,QW
ap+a M ',csbw-
-6 M N 16111
d ? ??
IN1, Sk St CAC(, Si C
(Dates)
Feb?) 7 - M A? 07
14 1R+? aln? ?Une- 0
The mother of the child is<ettc?I ?r currently residing at
(mother's name)
??$ E.??? P?ta? i'?ac?,?ic?b?.?°? PA r?1?SS ?umb??ldn?__ _.
(Street)
(City) (State)
Code) (County) (Telephone)
She is ('married ?divorced ?single ).
The father of the child is?C?Q,r , currently residing at
(father's name)
Pv-?¢(5 Otn 0
(Street)
(City)
kk4N PA
(State) (Zip Code)
I i'l q?G-C4?d
(Telephone)
He is ( ?married ?divorced Osingle ).
4. The relationship of Plaintiff to the child is that of
(mother, grandfather, etc.)
The Plaintiff currently resides with the following persons:
Name Relationship
5. The relationship of Defendant to the child is that of o?
(mother, grandfather, etc.)
The Defendant currently resides with the following persons:
,1n Name Relationship
U1?iiL;i?p+r`k
?V??,? ?t??s?W4,Av\ s??
6. Plaintiff ( Uhas 4has not) participated as a party or witness, or in another
capacity, in other litigation concerning the custody of the child(ren) in this or another
court, including but not limited to: child support, protection from abuse,
guardianship, dependency, delinquency, criminal, or mental health. The court,
term and number, and its relationship to this action is:
Plaintiff ( ?has 5thas no ) information of a custody proceeding concerning
the child pending in a Court of this Commonwealth or any other state. The Court, term
and number, and its relationship to this action is:
Plaintiff ((]knows j[does not know ) of a person not a party to the
proceedings who has physical custody of the child or claims to have custody or visitation
rights with respect to the child. The name and address of such person is:
S;hce
1111M.) MI Ih gW5
7. The best interest and permanent welfare of the child will be served by granting
the relief requested because (set forth facts showing that the granting of the relief
requested will be in the best interest and permanent welfare of the children):
8. Each parent whose parental rights to the child have not been terminated and
the person who has physical custody of the child have been named as parties to this
action. All other persons, named below, who are known to have or claim a right to
custody or visitation of the child will be given notice of the pendency of this action and
the right to intervene:
Name Address Basis of Claim
Wherefore, Plaintiff requests the Court to grant. ?? O'CA °c\ of
(custody / partial ci d y/ visitation)
the child(ren).
Plfiintiff
I verify that the statements made in this Complaint are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa.
C.S.A. §4904 relating to unsworn falsification to authorities.
Plaintiff
ZC DEC Ct