HomeMy WebLinkAbout09-01-10 (3)
T
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
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~ ORPHANS"COURT DEVISION
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Plaintiff(s)
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mss, No. a o- o- v o~ g ~
Petition to Proceed In Forma Pauperis
and A~rthoutPofBond
TO THE HONORABLE, THE JUDGESIIOF SAID COURITff:
Pefitioner, cyor~ name, ~ ~ C VLF e~~ SAbel I (~, ,seeks
(please prbit yoar ems
leave to proceed in this matter in forma pauperis, and respectfully represents that: "
L I am the (indicate plainti,~''or defendant) p ~A~ n ~ ~ ~T - ~
proceedings. ~ 4
Court Term ~ u u 20 t d snd No. a0 ~o ~Qov6q
Page 3 of 11
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2. I reside at (state your, fidl address) ~ Dd F ~ 5~ ~ ~~ S t r e 2~ , ~ C _~ ~ ~~sT" C~
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3. , I have listed my sources and amounts of income truly and correcrtly on the
attached affidavit
4. I have the following average monthly expenses for the indicated items:
Housing: Insurance:
Utilities:= ': Transportation:
(Gas): ~ Medical:
(Oil): Loans:
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it .(Phone): Child Care:
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Food: `. Child Support:
Clothing:
5. I neither own nor have equity in any assets other than the following (state valtc~s 6i
dollars): .a a
6. I am unable to pay the costs of these proceedings or to obtain the amount of costs
from family or friends.
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Page 4 of 11
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Court Term ,a,r~ ~ 20 c0 and No. o o `l 6
WHEREFORE, Petitioner prays that heJshe be permitted to proceed in this matter in
forma parrperis.and without the payment of bond..
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.. Petitioner (prht your oane)_
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Petitioner (s~. roar ume)
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