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Home My WebLink About13-6239 • IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA CIVIL DIVISION THE COMMONWEALTH OF PENNSYLVANIA -177 t CO COUNTY OF ` ° ',_ akh16c., c" 1\3 �°G��i,1sQc � 4� S' , F Ci c Plaintiff vs. No. 13- ba3q QTCrU' cc7/'7r Defendant PETITION FOR LEAVE TO PROCEED IN FORMA PAUPER'S AND NOW, comes the (plaintiff/defendant)/;;(0/6j ° and respectfully requests this Honorable Ccurt for leave to proceed in Forma Pauperis in the above captioned case. In support of this Pe'itIon, (plaintiff/defendant)avers as follows: 1. (Plaintiff/defendant) desires to commence a (Civil Action/Appeal)to the Court of Common Pleas but is without the funds to pay the filing fee. 2. (Plaintiff's/defendant's)financial affairs are set forth in a Verified Statement, a copy of which is attached to this petition as Exhibit A. 3. If(;:=;;intiff/defendant) is not permitted to commence a (Civil Action/Appeal) in Forma Pauperis, he/she will be denied due process of law and/or his/her rights under the Constitution of the United States and the Constitution of the Commonwealth of Pennsylvania. 4. (Plaintiff/defendant) has never been denied leave to proceed in Forma Pauperis in any case. Wherefore, (plaintiff/defendant)prays this Honorable Court to grant this Petition and to allow him/her to proceed without payment of the required fees. RESPECTFULLY SUBMITTED Plaintiff/Defendant O� IN THE COURT OF COMMON PLEAS OF ANNONINI.COUNTY, PENNSYLVANIA CIVIL DIVISION . ..- ow THE COMMONWEALTH OF PENNSYLVANIA COUNTY OF tiQ: -r 11- 4s' Lee_ 'd ° 2- Plaintiff v No. /s. / / ,LE C 2 Clod° s Zee c. Z. 5 Defendant IN FORMA PAUPERIS VERIFIED STATEMENT 1. I am the (plaintiff/defendant) in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending this 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 and costs is true and correct: / (a) Name: f/-EG'2%2-1 Z G0Z inaffilliallara Address:. /( L A;2"--v-e__ Phone: 2-°'%/ City: a s1 j State: /.-i Zip Code: '77 -0- /off (b) EMPLOYMENT If you are presently employed complete the following: Emoloyer: ,,(7;-,//71-- ,t'/;/ Phone: -4//f' Address: !> 1��j -/ -1 Employee ID: /Y/ City: /L i/ State: Zip Code: /' - /� Monthly salary or wages: $ /%/ Type of Work: /�� (e) PROPERTY OWNED Cash: $ /f,�'t f Checking Account: $ ��71' Savings Account: $ '7O77 Certificates of Deposit (CD's): $ $ i . ' Real Estate (including house):$ Motor vehicle(s): Make: // � Purchase price: $ /'/ Amount owed: $ Make: /3r7, Model: Year: Purchase price: Amount owed: $ /1/7 Other (explain): $ (f) DEBTS AND OBLIGATIO Mortgage: $ ent. $ Loans: $ Other(explain): $ ( (g) PERSONS DEPENDENT UPON YOU FOR SUPPORT (Wife's/Husband's) Name: 4-- Children, if any: Name: Age: Name: Name: /1/ Age: Other persons: Name: 4;% /� Relationship: Name: 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. 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., paragraph 4904, relating to unsworn falsification to authorities. DATE: — 7"/13 PETITIONER: If you are presently unemployed, please complete the following: Date last worked: cvtij ,,e --k---7,6e..-z_ Monthly salary or wages: $ _/_w7 //_.-",-7A 604--- Type of work: _ Z ( Se.Gc-t, 1 s4/3. "-477 (Ss'2) (c) OTHER INCOME WITHIN THE PAST TWELVE (12) MONTHS (list amounts and explain) Business or profession: $ 4 -//-'/I. Other self-employment: $ /. Interest earned: $ Dividends: $ /v /, Pension and annuities: $ /L - . - — ,.. _ _Socia_L$cairn* efits - Support payments: $ 4,-;:-/---/9- Disability payments: $ ,7P - Unemployment compensation and supplemental benefits: Workmen's coroner-sation: $ -4-.-" � Public Assistance: $ /1'/ -' ' Other(explain): $ (5.-__S- j_s'cc--;7e:.(i s"�cU1/I /7 c, s,,6%Z:; ,�- (d) OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT (Wife's/Husband's) Name: /9cr4 'e: -E Lac 2/`- C" 4.7.-- — Employer: 4-- --:/r ---2 7,'" j/ / .7 Phone: '1,'7r Address: /L%/% .,ir ,J.1 4-- 2 Employee ID: ..4"i ' City: ///,i i/// 1 State: Zip Code: � :f Monthly salary or wages: $ /J :/ Type of Work: /,�. - Contributions from children: $ �� l.22 Contributions from parents: $ 47: Cle/sl"':, Other contributions (explain): $ /7 %. ,- %f �i' -‘✓% 0 Integrated Offender Case Management System 10/1/2013 8:20:56 AM Monthly Account Statement From Date: 9/1/2013 To Date: 10/1/2013 Institution: COA- Coal Township 12:00:00 AM 12:00:00 AM Location Case 10 Offender Name Current Balance Escrow Balance COA-H-A-2017-01 GZ8313 COLLINS,FREDERICK -438.39 0.0C ...yam s ,a. •,� - .„ . .Y.,y",`... 3 ?'e .. `"� .: nkr , z` »; ..S34'.:5y Batch Txn Date Txn Description � � {'>�i�°Ariiount{$'� ' aianeAffr- Transaction($) COA-017631 09/30/2013 : 41 -Medical Co-Pay -5.00 -438.39 9/27/13 09/27/2013 Transfer In -433.39 Coal Township 09/27/2013 Transfer Out' -433.39 Camp Hill CAM-018878 09/04/2013 37 Postage -3.10 -433.39 first class mail Available Balance -438.39 Page 1735 of 2257 IN THE CO RT OF COMMON PLEAS - `-' • � n/tl�r,✓ COUNTY, PENNSYLVANIA In Re the Petition of: (PRINT YOUR NAME)''; `..`. 13 - coa39 c2ivitTerm For a Name Change to: Docket No. A6--G J� f,1f� .�zso�✓ i3 /-��n (PRINT NEW NAME) VERIFIED PETITION FOR A NAME CHANGE And now comes Petitioners) i� By this petition and upon being duly sworn, respectfully represents and shows. unto the Court: 1. That the Pe 'tio er s is •f full legal age and is a bonafide resident of the County of ; ;`v ommonwealth of Pennsylvania, whose resides at : 4e-iL2e' v c.%t l iiL (,CCL/XiIv'✓Sjr.%7,%9,9. /-7g /G: , Petitioner(s) has been a bona fide resident of County, State of F Pennsylvania fors,, -„,,��e�, fi iV ) immediately prior to filing this Petition. Petitioner(s) was born on the day of 4/ove.#//6 .. (month), /, (year), in the County of„la, State of ��%�%��✓� , 9ec+n 71/e / Country of ,� sip yes ("r” e r=� . cyo� ��c>,S' 2. Petitioner's present name is i�e �� /e e_ c c� S 3. Petitioner(s) is eiimarried 45 married ts2.....): xZt.e- 4. That the Petitioner(s) is the )(' Father Mother of the following minor children. None: Name Birthdate Age t/ .1` 6)&3,2 Qi,4/1,7 5. Petitioner(s)has resided at the following address(es) over the last five(5) years: /e6,0 / W_Z*2 /Le/1z 67.4-z7 /7oc, 6. That the Petitioner(s) pray's for the change of name for the following reasons: Describe in detail: z_z c-Z ,-e 01,717-r /712_,/ few, 6-},ves_7: 7. cz3,/-7 X <c7 AZ 7fr%rec AvZ; r.)6- 172;-7,-- sy .?-;/;1 - ey've;r(r.„ v s 7-&, .frte 6,4 AYV ;" • That the proposed change in the Petitioner(s) name, if granted, will not be detrimental to the interests of any other person and is not against the public interest. This petition is not filed to defraud creditors. Wherefore, the Petitioner(s) pray(s)that by an Order of this Court,made and entered herein, the Petitioner(s) name be changed to and decreed to be: /i ?%"4 Jam.4c4/% G2ke_r2,_ Respectfully Submitted, •(41 4 1,q L9. Signature Address: ? ems Phone: Iii t ; pURT OF COMMON PLEAS ■ COUNTY, PENNSYLVANIA VERIFICATION I, /E,4 e c' iz z c� � . .� �_ T �f , veri fy that The statements made in the foregoing Petition are true and correct to the best of my knowledge or information and belief. I understand that this verification'is made subject to the penalties of 18 Pa. C.S.A. Sec. 4904 relating to unsworn provides that if I knowingly make false averments, I may be subject to criminal penalties. /l? z % Date Signature IN RE: PETITION FOR CHANGE OF : IN THE COURT OF COMMON PLEAS OF NAME OF FREDERICK DOUGLAS : CUMBERLAND COUNTY, PENNSYLVANIA LEE COLLINS : 13-6239 CIVIL TERM ORDER OF COURT AND NOW, this (34-154 day of November, 2013, before the court is Petitioner's Petition for Leave to Proceed in Forma Pauperis wherein the underlying matter involves a petition for a name change. The Petitioner filed a similar petition for a name change at 13-4473 Civil Term, which was denied by the Honorable Christylee L. Peck on October 17, 2013 because the Petitioner "failed to meet the statutory requirements for a name change (see 54 Pa.C.S.A. §702(c))." Further, it is apparent that the Petitioner does not meet the threshold requirement of being a "resident in the county" pursuant to 54 Pa.C.S.A. §702(a). Therefore, pursuant to Pa.R.C.P. 240(j)(1), the Petition to Proceed in Forma Pauperis is DENIED, and the underlying petition for name change is DISMISSED with prejudice. By the Court, de( Albe r H. Masland, / Frederick Douglas Lee Collins, GZ-8313 2 SCI-Coal Township m o 1 Kelley Drive =m ° - '" Coal Township, PA 17866-1020 j t,ee > o :sal eop-i III I to O nz ' r pllB zcp c �r ..r