HomeMy WebLinkAbout08-04-10IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION -LAW
In re: BELLA SHEEDER,
A minor child No. 02/ _ /Q - °7902.
Petition for Waiver of Costs
1. I am the Petitioner in the above matter and because of my financial condition, I am unable
to pay the fees and casts of prosecuting or defending this action or proceeding.
2. I am unable to obtain funds from anyone, irtduding 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 corned:
(A) NAME: Stephanie Hollen
ADDRESS: 3800 Golfiew Dr, Mechanicsburg, Pa 17050
(B) EMPLOYMENT:
If you are presently employed, state:
EMPLOYER: American Legion Post #109 ti
ADDRESS: 224 Main St, Mechanicsurg, PA 17055 ~o ° ~- ~ '~
rr~
SALARY OR WAGES PER MONTH: $ 731 r n
c7 c
~ ti
~
TYPE OF WORK: Bartender
cn ~ ~-i i~j
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.
If you are presently unemployed, state: ;off . .~
a C' ~ ~~'
DATE OF LAST EMPLOYMENT: ~ ~ ~ -~ n,
SALARY OR WAGES PER MONTH: ~
TYPE OF WORK:
(C) OTHER MONTHLY INCOME WITHIN THE LAST TWELVE (12) MONTHS:
BUSINESS OR SELF-EMPLOYMENT: $ 0
INTEREST OR DIVIDENDS: $ 0
PENSION OR ANNUITIES: $ 0
SOCIAL SECURITY OR S.S.I.: $ 0
SUPPORT: $ 0
UNEMPLOYMENT COMPENSATION: $ 0
WORKER'S COMPENSATION: $ p
WELFARE: $ 540 (Food stamps:
monthly)
OTHER (Please specify): $ 0
(D) OTHER MONTHLY CONTRIBUTIONS TO HOUSEHOLD SUPPORT:
In re: BELLA SHEEDER Petition for Waiver of Costs Page 2 of 4
SPOUSE'S NAME (if living together): (Not applicable)
If your spouse is employed, state:
EMPLOYER:
SALARY OR WAGES PER MONTH:
TYPE OF WORK:
CONTRIBUTIONS FROM CHILDREN: (None)
CONTRIBUTIONS FROM PARENTS: (None)
OTHER CONTRIBUTIONS: (None)
(E) PROPERTY OWNED:
CASH: (None)
CHECKING ACCOUNT: $ 5
SAVINGS ACCOUNT: (None)
CERTIFICATES OF DEPOSIT, STOCKS, BONDS:
REAL ESTATE /HOME: (None)
MOTOR VEHICLE:
(None)
Year Make and model Cost Amount
still owed
1997 Eagle Vision Esi $ 1,500 $ 0
OTHER: (None)
(F) DEBTS AND OBLIGATIONS PER MONTH:
MORTGAGE/RENT: $ 600 WATER/SEWER:
ELECTRIC: $ 150 TELEPHONE:
OIUGAS/HEAT: $ 120 CABLE:
FOOD: $ 75 CLOTHING:
CHILD SUPPORT: $ 0 CHILD CARE:
TRANSPORTATION: $ 0 MEDICAL EXPENSES:
LOAN PAYMENTS: $ 0 CREDIT CARD PAYMENTS:
INSURANCE: $ 0 MISCELLANEOUS:
(G) PERSONS DEPENDENT UPON YOU FOR SUPPORT:
CHILDREN (STATE NAMES AND AGES):
Name q~
Bella Sheeder 11 months
OTHERS (STATE NAME, AGE ANO RELATIONSHIP):
Name Age Relationship
(None)
$ 45
$ 250
$ 0
$ 100
$ 130
$ 0
$ 0
$ 0
In re: BELLA SHEEDER Petition for Waiver of Costs Page 3 of 4
3. I understand that I have a continuing obligation to inform the court of any improvement in
my financial circumstances which woukf permit me to pay the cost incurred with this case.
4. 1 verify that the facts stated in the foregoing Petition are true and correct to the best of
my knowledge, information and belief. Petitioner understands that false statements therein are
subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities.
Date:_~ `~ lG
In re: BELLA BREEDER
ST HANIE HOLLEN, Petitioner
Petition for Waiver of Costs Page 4 of 4