HomeMy WebLinkAbout09-01-10 (4)
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
~i L`n ae:l ~~
6 e(Ir~ GDSI ~S
~Q ra
o
,
ros
P
(your name) e ~ ~
~ . ~ -° ~ cn
ro
~ ,~~
50o Ea,St ~ly5f~e~~' ~
~~
~
C~
~'
1 ~
Lu1
3
1
41I G53) ~,
J
~
.
~/ a N
(area code and Telephone number)
.. ~,.
.
AU~~ USA
TERM, 20 /0
.
~ ~ ~tota~ ~ lYem)
rl~ G,~P ~~ bP ((& G
~ gs~
Plaintiff(s)
VS.
~.5~'~~e o~ Dam,n~GlC~I ~~q.:
D ~ y ~ ~ "~~~ ~ ~
efendant(s) N0. b
Peh~ioner's Affidavit
Pursuant to PA. R GP. 240
COMMONWF.~4LTHOFPENNSYLVANIA
SS. r 7 s"~ 4 8 ~ ~~, ~a
1. I, ~~~~ Rp~ c~~~/~ l~ , am the(Defendant)
cu~ele one)
in the above mattes and because of my financial condition am unable to pay the fees
and costs of prosxuting or defending the action or proceeding.
f"
c
.'.3 . ^ ~
r~}~ ~
:~ r t
~..:,
.,,
(~ 1'Y'"~
_} ) 1'
c -". ,:-7
_,,
_,-,
'.a .. J
f ._ : "Tl
•..~'~
.r 2
4
Page ~6 of 11
~~
~ r.
Z. I am unable to obtain funds from anyone, including my family end associates, to pay
thc, 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: S(70 E ~ S~" ~ ~"~
C Ine~~~ ,~ PA 1 q 0 (3 -
~75 ~ 8-~~(~t ~
Social Security #
(b) EMPLOYMENT .. °~,
Ifyouare-presently employed, state:
);mployor : ~ /~
Address: /~
`' Salary/wages ,~ / ~ '~
Per Month: f V
Type of Work: /V ~C '
. IfYou are presently uaemplnYerl,Ast~ate'
Date of last Employment: / Y /~
Salary/Wages '
Per Month: / V
Type of Work: N /~
(c) OTHER INCOME WITHIN THE PAST Zr'WELVE (I2) MONTHS
(state as dollar amounts) . - n c, ~ ~ cerp~f ~o n g ~ h'c
Business or Profession: /~ ~ i ^'~ 1 ` a 00 9
Other Self-employment: ,/~ ~
~.
~,,
- - Page 7 of 11
Interest: /(~ ~ r
Dividends:/~~
1• -~ t
Pension and Annuities: /~l~ -
Social Security Benefits: ~ V
..Support Payments: ~,/~/
Disability Payments:~~
Unemployment Compensation & ^ /
Supplemental Benefits: / V
VJorkmans' Compensation: ~/ ~
~\ ~~
Public Assistance: `':
other: :iUb _
(d)''O~HER CONTRIBUTIONS TO SOUSF.H'~pLD SUPPORT (state as dollar amountr)
(Wife) (Husband) (Friend) Name: /~ C~' '
If your (wife) (kusbaxd) (f*ieadl is employed; state:
Employer: i(/'D ~.
Salary/Wages '
Per,Month: lV
Type of Work: / I/ [l
Contributions A / n
From Children: /1/ U
Contributions ,~
From Parents: ~ V ,~ /
Other Contributions: /t/ CZ..__
(e). PROPERTYO.WNED (state as dollar amos)
Cash: ,/~
Page 18 of 11 -
~•.
Checking Account: /~l b r
savings Account: N G
_ `
Certificates of Deposit: /\/ p k
Real Estate
(Including Home): /1~ .D
Motor Vehicle: Make _ /V ~ y~
Cost $ ,/Il. ('~ Amount Owed Z
Stocks & Bonds: /~/~ C~
Other: ... N' D
--
(f) DEBTSa+l1VD OBLIGATIONS (stafe as dolClar amounts) .
Mortgage: /~~
Rent: /I~Q - 1
Loans: . ~Q ~ ~ . .
Other: l ~ .
(g) PERSONSDEPENDE'Ny' UPONYOUFO$ SUPPORT
(DVife) (Husband) Name: /~t) /1~e
Children, if anY~ /V'h Yl e Ag
e
Age
Age
Age
Other Persons:
Name:_ /Il D
Page 9 pf 11
r~
_~~
Relationship;
4. I understand that I Kaye a contin
umg obligation to inform the Court of improvement in my
financial circumstances which would permit me to pay the costs iacua~ed 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 unswom
falsification to authorities.
.a.
•\,
Dazed: `g ~ a ~ ~ ~A• {J ( ..a \
Petitror~er (Prrrct your ~eame) 1
r/l
• Petrtioner (Sign your name)
Sworn to and subspibed before me this
~' of 20
Notary Public
F,
F.
~:
Page 10 df 11
f
• ~r. (,
Certificaite of Service
I ~~~' certify that I have served a copy of this petition upon all other parties or their
attorney of record by:
Please chec~•
X Regular First Class Mail
-•---.._.__Certified Mail _
Other
.;
Name of.Petitioner ,(Print Name)
~iL/~,hol! /A/. ~,.
Signature of Petitioner (Sign your name)
~,c., Lurn~e~~~w~ C ~ ~o~r~ (~
o~~ 052
~ COU <"~' ~ OUSe
cL ! ~vAr2,' C,A~I-S~~ Ply 1 ~0~~
~V~6'2f ~f~W ~ir~
~-J,~rr,SbU~~ P,~ -~ Ib~-~ fbb~
~~
4,
I \.
Page 11 ~f 11
i
~~~
~ ~.
~~
~~ ~-I
~, ~
r
~a ~i.~ N
~~111~if'~ o
~,~
A
N~
/w
k~ ~
M
~ ~~ ~
e
4
4
~t
~.
• Q
~/
~ J
~ j
/ `~
Q
`
~
~~ ~y
~
~ ~
~ / ~ _
~
>
0
v
~ ~
~
{ ~ ~~ O v
~"'
W M
w r ~
~ 4 ; .. ~ ~i
f- ~ ~.
~ ~
W.L.d
~ ~
~~¢ ~
r¢~
Uww
0
tn~°U
CYO
0
~s
~I~
T
~A
~~
~~
ti
w++
.ti
p~
1