In Forma Pauperis Affidavit/Petition (AOPC 622A) – Pennsylvania Magisterial District Court Completed Form Examples and Samples
Explore a detailed, filled example of the In Forma Pauperis Affidavit/Petition (AOPC 622A) for Pennsylvania Magisterial District Courts. This sample AOPC 622A form provides a clear guide on how to correctly complete the petition to waive court filing fees in PA.
Filled In Forma Pauperis Affidavit/Petition (AOPC 622A) – Pennsylvania Magisterial District Court Example
How this form was filled:
This example shows a completed AOPC 622A form for an individual seeking to waive court filing fees. The petitioner qualifies for In Forma Pauperis status because they receive public assistance (SNAP), which is indicated in Section 1 of the form. The financial affidavit section is also filled out, providing details on income, assets, and household size. All case-specific information, such as the petitioner, defendant, and court details, are included.
Information used to fill out the document:
- Petitioner / Plaintiff Name: Jane M. Smith
- Petitioner / Plaintiff Address: 123 Apple St, Apt 2, Harrisburg, PA 17101
- Petitioner / Plaintiff Phone: 717-555-1234
- Defendant Name: John T. Davis
- Magisterial District Number: 12-1-01
- County: Dauphin
- Docket Number: MJ-12101-CV-0000123-2026
- Reason for Petition: To file a civil complaint without payment of costs.
- Public Assistance: Yes, receives SNAP benefits.
- Household Size: 2
- Monthly Gross Income: $800.00
- Cash / Bank Accounts: $150.00
- Property Owned: 2012 Toyota Corolla, value approx. $3,000
- Signature: Jane M. Smith
- Date: 03/10/2026
What this filled form sample shows:
- Correctly identifies the petitioner, defendant, and court information.
- Clearly states the petitioner is seeking to proceed with a civil complaint.
- Demonstrates qualification by checking the box for receiving public assistance (SNAP).
- Accurately lists income, assets, and household size in the financial affidavit section.
- Includes a properly executed signature and date for verification.
Form specifications and details:
| Form Name: | In Forma Pauperis (IFP) Affidavit/Petition |
| Form Number: | AOPC 622A |
| Jurisdiction: | Pennsylvania Magisterial District Court |
| Use Case: | Individual receiving public assistance seeking to waive filing fees for a civil complaint. |
Created: January 29, 2026 07:53 AM
