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HomeMy WebLinkAbout94-05032 " , , ,'I " " , , , , , , , . ;;P " " \i. " , ~ j , , I') , ill ), ~ rf) ~ , ' I 6=) .1 -l' \/I( /In/ ( /)),'/1', Ii// ) H, III If' /I{t,-! Jr., (I;,: f,'(/), l J,/, l ("d ) 7J.l' 'i'l- .M.~..L C!<,;~ -r;,.-... SEP 0 7 199~ J;v 1. AFFID~VIT IN SUPPORT OF PETITIQH FOR LEAVE TO PROCEED IN FORMA PAUPERIS I am the 11(/ { ~i I, (( in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting, defending, or appealing 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 (a) fees and costs is true and correct. J If.,(/ti <'/I('llr'l\ 1'( 1)('1_ /(';'1 ((U,!,.j,', 1\,/1 PU.... IIi! 'il! /.1' ( Name: Address: Social Security Number: (b) If you are presently employed, state 1\,,( flf' Employer: Address: Salary or wages per month: k'( Ifl ,'.", ' Type of work: If you are presently unemployed, state '. Dat,e of last employment: /( .. #t40C, ~~/iary or wages per month: 4/1 l ,) Type of work: (' I,'f'/(d / A h,LU, ( "_...... 'l~ ,'1'{ II- I ! V' v' r......r:l,(( (c) Other income within the past twelve months Business or profession: Other self-employment: ~ stocks, bonds: N"I"I( Other: ObligatiOn'\ (f) Debts and Mortgaget f, / " r,,( v I' Rent: II Loans: I' Monthly Expenses: (g) Persons dependent upon you for support (Wife) (Husband) Name: it' ~ Children, if any: Name: Age: 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, 4904, relating to unsworn falsification to authorities. Date:! I '/ ,/ r . ) , f " - ", i I .,/, ,~;., -I { [1'/ , . ".. . I '/0/1'1 II ( I , , CJ; ::1": . ., ~ I , ., '" '.' 'e: . '." ;.:~ r./'" .'" " ,. ~ "" " '. " - , r r-- ":. . fb " . , ..,., 'l.. if>.~d {t S I(~. (/nJ ( Pia,. N.I, '.(f) V~. tLI'c/lae I JOCKS~N(/JefeMJ(Nf) tr: , ' , ,~; .. ((f SEP 07 1994 J;v. AFFIDAVIT IN SUPPORT OF PETITION FOR LEAVE TO PROCEED IN FORMA PAUPERIS 1. I am the PlaiN+,'ff in the above matter and because or my tinancial condition am unable to pay the fees and costs or prosecuting, defending, or appealing the action or proceeding. 2. I am unable to obtain tunds trom anyone, including my tamily and associates, to pay the costs ot litigation. 3. I represent that the intormation below relating to my ability to pay the tees and costs is true and correct. L ,'u:la S I\E' f-k-tJ p, O. fSc:X_ /c59 C{U~..I,'s/-E'1 r A J7{;/3 social Security Number: J 9:1 - if l./ - I/J?O (a) Name: Address: (b) It you are presently employed, state ^/D}/t: Employer: Address: Salary or wages per month: ~ ttaRE Type or work: It you are presently unemployed, state Da~e of last employment: Ie - 1~, 1If1~tJ6~l~rY or wages per month: 'AJ (,'r/:' Ii I {' r t,r- Type or work: CJef:!.ic.a./ I/J f .:~ t ~'dCt!..c ~Cf'N (c) Other income within the past twelve months Business or prOfession: Other selt-employment: " Interest: Dividends: t..Jo ~e NotJe Pension and annuities: social Security benefitsl support payments I Disability payments I Unemployment compensation and supplemental benefits: Workman'. compensation: public Assistance: f Ie r(. CO ttr, e.s-!-i~tu:Je -G~, 111l) other: (d) other contributions to household support (wite) (Husband) Name: "1/"'1 "r-P If your (husband) (wite) is employed, state Employer: Salary or wages per month: Type of work: contributions from children: (e) Property owned Cash: Nn N€- Checking Account: Savings Account: Certificates of Deposit: Real Estate (including home) : Motor vehicle: Make Year Cost Amount owed . "; '-',!);/'II_;:< J,'IlJ.'Jl!~ :\1 7,Li~'J+ ';~.: ~j_ ; " ',,.r;';,.. ,::;.;:.~~ -~..~' ...j;lSl..,-J' ~ r.!15ei:c;t1Sf;'alJINt~(..,tJ..l> ,_",fA ~~:~-~;;:I'lrl~I:~:.'~~;.c.II:,:, 1.. . ,",_, J""I~:~"..I;"..1 ~.'.... .' . ' \ .., ' " ,IllY",,;,'.:," , ' ~:~liii&ij~~ff)( ." '" .. stocks; bonds: ~e Other I ObligatiOn.~ (t) Debts and Mortgage: NO rJe Rent: I ( I , Loans: II Monthly Expenses: (g) Persons dependent upon you for support 51'" r P- (wite) (Husband) Name: Children, it any: Name: Age: 4. I understand that I have a continuing obligation to inform the court ot 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. 4904, relating to unsworn falsitication to authorities. Date: 1-1-7'-/ ('4j&-~ " '-Ph' II ..--... ) ai.N.ti.fJ/ . ~. -. 0; :'~':~':;'('/.~~~ "i:,~r'lt,;i\~'-I\." 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