In Forma Pauperis Affidavit/Petition (AOPC 622A) – Pennsylvania Magisterial District Court Instructions

Check this box to acknowledge you understand you must inform the Court of any changes in your financial circumstances that would allow you to pay the costs incurred in this case.

Check this box to certify that the statements made in the petition are true and correct and that you understand false statements may subject you to penalties under 18 Pa. C.S. § 4904.

Check this box to certify that this filing complies with the Unified Judicial System of Pennsylvania's Case Records Public Access Policy regarding submission of confidential versus non-confidential information and documents.

Enter the check number for the $90.25 appellate court filing fee payable to the Appellate Court. Fill only if 'Check # ______ in amount of $90.25 payable to the Appellate Court' is 'Yes'.

Check this box when you are attaching the appellate court filing fee check in the amount of $90.25 to the form.

Enter the check number printed on the payment made for $50.00 payable to the Clerk of Judicial Records — Criminal Division. Fill only if 'Check # ______ in amount of $50.00 payable to Clerk of Judicial Records - Criminal Division' is 'Yes'.

Check this box when you are attaching a check for $50.00 payable to the Clerk of Judicial Records (Criminal Division) as the required fee.

Check this box when you are attaching a copy of the request for transcript to this Notice of Appeal.

Check this box when you are attaching the copy of the docket entry referenced in the form as evidence of the docketed order.

Check this box when you are attaching a proof of service that shows all parties in the trial court, the trial judge(s), court reporter(s), and the district court administrator were served.

Enter the check number used to pay the deposit for transcription costs. Fill only if 'Check # ______ for payment of deposit(s) on transcription costs' is 'Yes'.

Check this box when you are attaching a check (enter the check number) to pay the required deposit(s) for transcription costs.

Enter the attorney's signature (typed or handwritten full name) signing this form.

Enter the attorney's primary mailing address (street address or P.O. Box).

Enter the attorney's city, state and ZIP code or any additional address details (apartment, suite, etc.).

Enter the attorney's daytime telephone number including area code and extension if applicable.

Enter the attorney's Supreme Court or bar identification number.

Enter the name of the party the attorney represents (for example, 'Commonwealth' or 'Defendant' or the party's name).

Provide the attorney's or requester's signature (or typed name if submitting this form electronically).

Enter the primary mailing street address for the attorney/requester (street number and name).

Enter additional address details such as suite/unit, city, state, and ZIP code for the attorney/requester.

Enter the attorney's best contact telephone number, including area code and extension if applicable.

Enter the attorney's Pennsylvania Supreme Court identification (bar) number as registered with the state.

Enter the name of the party the attorney represents in this case (for example, 'Defendant', 'Commonwealth', or the party's full name).

Enter the full legal name of the party appearing on the left side of 'vs.' (typically the plaintiff or petitioner) as it should appear in the case caption.

Enter the full legal name of the party appearing on the right side of 'vs.' (typically the opposing party) as it should appear in the case caption.

Enter the defendant's full legal name as it should appear in the case caption.

Enter the name of the plaintiff or left-side party as shown in the case caption (e.g., the charging authority or Commonwealth).

Enter the name of the defendant or right-side party as shown in the case caption (short/inline form used beside 'vs.').

Enter the defendant's full name exactly as it should appear on the case caption (full, extended name field).

Enter the full legal name of the plaintiff or petitioner in this case as it should appear on the court record.

Enter the full legal name of the defendant or respondent in this case as it should appear on the court record.

Enter the petitioner/plaintiff's full mailing address, including street, city, state, and ZIP code.

Enter the defendant/respondent's full mailing address, including street, city, state, and ZIP code.

Enter the name of the attorney, law firm, or other contact person associated with a party, or the name and contact details of any additional party to be listed.

Enter the court-assigned case number for this matter exactly as it appears on official court documents.

Enter the Offense Tracking Number (OTN) associated with this defendant/case as recorded by the court or law enforcement.

Enter the court case number assigned to this matter as shown on official court documents (include any letters, dashes, or spaces exactly as provided).

Check this box when the matter is a criminal case (use when the form pertains to a criminal proceeding).

Enter the OTN (official tracking/identification number) for this case as it appears on related records, including any letters or digits.

Check this box if the case being filed is not a class action suit (it does not seek to represent a class).

Check this box if the case being filed is a class action suit (the plaintiff seeks to represent a class of persons).

Enter the clerk's duplicate or file-copy indicator (the short code or number the clerk uses to mark this sheet as a duplicate or to identify the copy).

Check this box if the action is being commenced by filing a petition.

Check this box if the action is being commenced by filing a complaint.

Check this box if the action is being commenced by filing a writ of summons.

Check this box if the case is being commenced as or recorded as a transfer from another jurisdiction.

Check this box if the action is being commenced by filing a declaration of taking (eminent domain).

Check this box when, for an appeal by the Commonwealth pursuant to Pa.R.A.P. 311(d), the Attorney for the Commonwealth certifies that the order being appealed will terminate or substantially handicap the prosecution.

Enter the name of the county where this petition is filed (e.g., 'Allegheny').

Enter the top reference used to identify this matter, such as an internal file number, docket/reference code, or other case identifier.

Enter the county, division or prosecuting office associated with the Commonwealth's filing on this case.

Enter the short docketing or court division code used by the court for this case (a small internal code or prefix).

Enter the court-assigned case number for this matter exactly as it appears on official records.

Check this box to mark the first caption line for the plaintiff entry reading 'COMMONWEALTH OF PENNSYLVANIA' when that is the plaintiff in this case.

Enter the name or short identifier of any additional party or the party listed immediately before 'vs.' in the caption.

Check this box to mark the caption separator line ('vs.') in the court caption when completing the case caption fields.

Enter the OTN or offense tracking number assigned to the incident or arrest for this case.

Enter the full name of the defendant as it should appear in the case caption.

Check this box to mark the defendant line in the caption (the line next to the labeled 'Defendant') when that party is the defendant in this case.

Enter the primary court heading as it should appear at the top of the page (for example the court name, county and state or any official court designation).

Enter the name of your current employer (company or organization).

Enter your full legal name as used in employment records.

Enter the primary street address for your employer (building number and street name).

Enter additional employer address information such as apartment, suite, floor, or unit.

Enter the city where your employer's address is located.

Enter the state where your employer's address is located.

Enter the ZIP or postal code for your employer's address.

Enter your salary or wages per month as received from your employer.

Enter a summary of your debts and obligations, including relevant details such as creditor names, account types (mortgage, rent, loans, other), outstanding balances, and any brief explanations or clarifications.

Provide any additional or supplementary information about debts not covered above, such as payment schedules, co-signers, special terms, recent changes, or other pertinent notes.

Enter the total dollar amount for loans owed (the loan balance) associated with your debts and obligations.

Check this box if you have outstanding loans to report under Debts and Obligations and will enter the loan amount in the adjacent dollar field.

Enter the dollar amount you pay for your mortgage.

Enter the total amount owed for other debts not listed (the outstanding balance for miscellaneous debts).

Enter the current monthly rent payment amount you are responsible for.

Enter the dependent's full name followed by their relationship to you (for example: "Jane Doe — daughter").

Enter the ages of all minor children who depend on you, separated by commas (for example: 3, 7, 15); leave blank if you have no minor children.

Enter the relationship of this other person to you (for example: friend, sibling, parent, roommate). Fill only if '1. Other Person (Non‑Minor)' is 'Yes'.

Enter the full name of the other non-minor person who is dependent upon you for support. Fill only if '1. Other Person (Non‑Minor)' is 'Yes'.

Enter the full name of the non-minor dependent (the second other person) for whom you provide support. Fill only if '1. Other Person (Non‑Minor)' is 'Yes'.

Enter your relationship to that non-minor dependent (for example: friend, parent, sibling, roommate). Fill only if '1. Other Person (Non‑Minor)' is 'Yes'.

Enter the number of other non‑minor persons (dependents) who rely on you for support. Fill only if '1. Other Person (Non‑Minor)' is 'Yes'.

Check this box when you are listing an other person (non‑minor) who is dependent upon you for support (this marks the first non‑minor dependent entry).

Enter the full name of the spouse who is dependent upon you for support (provide first and last name as you want it recorded). Fill only if 'SPOUSE NAME' is 'Yes'.

Check this box when your spouse is a person dependent upon you for support and you are listing your spouse under 'Persons Dependent Upon Me For Support'.

Enter the total number of persons who are dependent upon you for support as a whole number (e.g., 0, 1, 2).

Check this box when you are attaching a check payable to the court reporter(s) as the required deposit to commence the requested transcription(s).

Enter the number of the check attached for the deposit payable to the Court Reporter(s) for commencement of the transcript(s). Fill only if 'Attached hereto is Check # (Deposit for Transcription)' is 'Yes'.

Enter the court docket number assigned to this case as it appears on court records.

Enter the date the case was filed in the court (the official filing date).

Enter the court docket number for this case exactly as it appears on legal documents (include any letters, hyphens, or slashes).

Check this box when the dollar amount requested in the case falls within the court's arbitration monetary limits.

Check this box when the dollar amount requested in the case exceeds the court's arbitration monetary limits and is therefore outside arbitration.

Enter the kind of work, job title, or primary occupation you currently perform or most recently performed.

If you are currently unemployed, briefly state your employment status or the reason for unemployment (for example, laid off, seeking work).

Enter the date when your most recent employment ended.

Enter the kind of work or job title for any additional or other employment you have.

Enter clerk-only filing information such as internal stamp details, filing date, initials, or short administrative notes related to this filing.

Enter clerk instructions or confirmation for filing in duplicate, such as a checkmark, date, initials, or short status note indicating the duplicate filing action.

Enter the small internal code, routing number, or office identifier used by the prothonotary for processing this document.

Enter the court-assigned docket number for this case as recorded by the prothonotary.

Enter the prothonotary's internal case reference or tracking number assigned for administrative use on this filing.

Enter the spouse's full legal name as it appears on official documents.

Check this box if the spouse named on the form is currently employed (has paid employment).

Indicate whether the spouse is employed (for example, 'Yes' or 'No') or provide a brief employment status.

Provide the name of the spouse's current employer. Fill only if 'Spouse Employment Status' is 'Yes'.

Enter the spouse's monthly salary or wages amount. Fill only if 'Spouse Employment Status' is 'Yes'.

Describe the spouse's usual job or occupation (for example, job title, duties, or industry). Fill only if 'Spouse Employment Status' is 'Yes'.

Enter the total amount contributed by the children toward household support.

Enter the total amount contributed by the parents toward household support.

Enter the total amount of any other contributions to household support not listed above.

Enter the total income you received from your business or profession within the past twelve months.

Enter the total dollar amount of disability payments you received within the past twelve months.

Enter the total dollar amount of dividends you received within the past 12 months.

Enter the total dollar amount of interest income you received within the past twelve months.

Enter the total amount of money you received from other self‑employment during the past twelve months.

Enter the total pension and annuity income you received within the past twelve months.

Enter the dollar amount of public assistance you received within the past twelve months.

Enter the total dollar amount of Social Security benefits you received within the past twelve months.

Enter the total dollar amount of support payments you received within the past 12 months.

Enter the total dollar amount of unemployment compensation and supplemental benefits you received (within the past twelve months) to report on your income.

Enter the total workers' compensation income you received within the past twelve months.

Enter the full legal name of the lead defendant (individual or business) as it should appear on court filings.

Enter the full legal name of the lead plaintiff (individual or business) as it should appear on court filings.

Enter the action, ruling, or order issued by the Magisterial District Judge for this case.

Enter the Magisterial District Judge's signature authorizing the action entered above.

Enter the full printed name of the Magisterial District Judge who signed or issued the action.

Enter the date on which the Magisterial District Judge signed or issued the action.

Enter the magisterial district number assigned by the county for this judge.

Enter the full name of the magisterial district judge (first and last name) who is listed as the contact.

Enter the primary street address or P.O. Box for the magisterial district judge's office.

Enter additional address information such as suite/apartment, city, state, and ZIP code for the judge's office.

Enter the judge's office telephone number, including area code and extension if applicable.

Check this box if the case is not an appeal from a Magisterial District Judge (MDJ).

Check this box if the case is an appeal from a Magisterial District Judge (MDJ) to the Court of Common Pleas.

Check this box if the plaintiff is requesting money damages in this action.

Check this box if the plaintiff is not requesting money damages in this action.

Check this box if your primary case is a civil appeal from the Board of Assessment.

Check this box if your primary case is a civil appeal from the Board of Elections.

Check this box if your primary case is a civil appeal from the Department of Transportation.

Check this box if your primary case is a statutory appeal from an agency not separately listed, and specify the agency on the lines provided.

Enter the specific statutory appeal information such as the agency, statute, or a brief description for ‘Statutory Appeal: Other’. Fill only if 'Statutory Appeal: Other' is 'Yes'.

Provide additional details or continuation for the statutory appeal (e.g., statute citation, agency name, or brief description). Fill only if 'Statutory Appeal: Other' is 'Yes'.

Check this box if your primary case is a civil appeal from a Zoning Board decision.

Check this box if your primary civil appeal arises from another source or agency not listed and describe the nature of the appeal on the lines provided.

Enter a short description of the ‘Other’ civil-appeal category or the specific board/issue you are appealing. Fill only if 'Other' is 'Yes'.

Use this second line to continue or add additional details about the ‘Other’ civil-appeal category entered above. Fill only if 'Other' is 'Yes'.

Check this box if the PRIMARY CASE is a contract action in which the plaintiff is a buyer.

Check this box if the PRIMARY CASE is a contract-related debt collection matter involving a credit card.

Check this box if the PRIMARY CASE is a contract-related debt collection matter not involving a credit card (specify type on the provided line).

If you checked 'Debt Collection: Other,' enter a short description of the type or source of the debt collection claim (for example, medical debt, utilities, or other creditor). Fill only if 'Contract: Debt Collection - Other' is 'Yes'.

Provide a brief clarifying note or short identifier for the 'Debt Collection: Other' item, such as an account suffix, short case note, or distinguishing code. Fill only if 'Contract: Debt Collection - Other' is 'Yes'.

Check this box if the PRIMARY CASE is a contract-related employment dispute alleging discrimination.

Check this box if the PRIMARY CASE is a contract-related employment dispute other than discrimination (provide details on the line).

If you checked 'Employment Dispute: Other,' enter a concise description of the employment dispute (for example, wrongful termination, wage dispute, or other issue). Fill only if 'Contract: Employment Dispute - Other' is 'Yes'.

Provide any short supplementary detail or identifier for the 'Employment Dispute: Other' entry, such as a claim code or brief clarifying note. Fill only if 'Contract: Employment Dispute - Other' is 'Yes'.

Check this box if the PRIMARY CASE is a contract matter not listed above and briefly describe the nature of the claim on the line provided.

If you checked 'Other' in the Contract category, enter a short description of the contractual issue not listed in the predefined options. Fill only if 'Contract: Other' is 'Yes'.

Provide a brief additional detail or identifier for the contract 'Other' entry, such as a contract clause reference, contract number, or clarifying note. Fill only if 'Contract: Other' is 'Yes'.

Check this box if the primary case is a mass tort involving asbestos exposure or asbestos-related claims.

Check this box if the primary case is a mass tort involving tobacco-related claims.

Check this box if the primary case is a toxic tort involving DES (diethylstilbestrol) exposure or related claims.

Check this box if the primary case is a toxic tort involving medical implants or implant-related injuries.

Check this box if the primary case is a mass tort involving toxic waste contamination or hazardous waste exposure.

Check this box if the primary case is a mass tort not listed above and use the adjacent lines to describe the type of mass tort.

Enter the primary brief description or name of the other mass tort category not listed above on the first available line. Fill only if 'Other (Mass Tort)' is 'Yes'.

Enter an additional brief description or name of the other mass tort category not listed above on the second available line. Fill only if 'Other (Mass Tort)' is 'Yes'.

Check this box if the primary case is a common-law or statutory arbitration matter.

Check this box if the primary case is a declaratory judgment action seeking a court declaration of rights or legal relations.

Check this box if the primary case is a mandamus action seeking a court order to compel a public official or agency to perform a duty.

Check this box if the primary case involves non-domestic relations matters (i.e., matters not classified as domestic relations).

Check this box if the primary case is a quo warranto proceeding challenging a person’s right to hold a public office or position.

Check this box if the primary case seeks recovery of possession of specific personal property (replevin).

Check this box if the primary case is a miscellaneous category not listed above and describe the primary claim in the provided blank lines.

Enter the first line of the brief description naming the 'Other' miscellaneous case category that best describes your primary claim. Fill only if 'Other (Miscellaneous)' is 'Yes'.

Enter the second line of the brief description for the 'Other' miscellaneous case category if more space is needed to fully describe your claim. Fill only if 'Other (Miscellaneous)' is 'Yes'.

Check this box when the primary case is a professional liability claim alleging dental malpractice or other liability by a dental professional.

Check this box when the primary case is a professional liability claim against an attorney or other legal professional.

Check this box when the primary case is a medical malpractice or other professional liability claim involving a healthcare provider.

Check this box when the primary case is a professional liability claim against a type of professional not listed above and specify the profession in the provided space.

Enter the first line of the specific professional type or short description for the 'Other' professional-liability category (e.g., the profession or specialty that best describes the defendant). Fill only if 'Professional Liability - Other Professional' is 'Yes'.

Enter the second line of additional details for the 'Other' professional-liability entry, such as continuation text, clarification, or further specification of the professional type. Fill only if 'Professional Liability - Other Professional' is 'Yes'.

Check this box when the primary case is an action to recover possession of real property (ejectment).

Check this box when the primary case is an eminent domain or condemnation proceeding.

Check this box when the primary case involves a dispute or claim concerning ground rent.

Check this box when the primary case is a landlord–tenant dispute (e.g., eviction, lease issues).

Check this box when the primary case seeks partition or division of jointly owned real property.

Check this box when the primary case is a residential mortgage foreclosure action.

Check this box when the primary case is a commercial mortgage foreclosure action.

Check this box when the primary case seeks to quiet, clear, or establish title to real property.

Check this box when the primary real property claim is not listed above and use the lines provided to specify the type.

Enter the first line of a short description naming the 'Other' real property category that best describes your primary case (e.g., specific issue such as 'boundary dispute' or 'leasing matter'). Fill only if 'Other (Real Property)' is 'Yes'.

Enter the second line of the 'Other' real property description to provide any additional clarifying details about the category entered above. Fill only if 'Other (Real Property)' is 'Yes'.

Check this box if the primary nature of the case is an intentional tort (a claim alleging intentional wrongdoing).

Check this box if the primary claim is for malicious prosecution.

Check this box if the primary case arises from a motor vehicle accident or related motor vehicle claim.

Check this box if the primary claim is for nuisance.

Check this box if the primary claim is premises liability (an injury or unsafe condition on someone else's property).

Check this box if the primary claim alleges product liability and it is not part of a mass tort.

Check this box if the primary claim is for slander, libel, or other defamation.

Check this box if the primary tort category is not listed above and provide the specific type of tort in the blank lines.

Enter the brief name or short phrase describing the primary 'Other' tort category that best describes your case (for example, 'Wrongful Termination' or 'Medical Malpractice'). Fill only if 'Other (Tort) - specify' is 'Yes'.

Enter any additional short detail or clarifying information about the 'Other' tort category entered above, such as a subcategory, specific cause, or brief qualifier (optional). Fill only if 'Other (Tort) - specify' is 'Yes'.

Enter the full legal name of the party filing this notice of appeal (the appealing party) exactly as it appears on the case.

Check this box to indicate the year of the order being appealed (i.e., when the order appealed from was entered), corresponding to the adjacent year field.

Enter the numerical day of the month on which the order was entered (1–31).

Enter the month name of the date the order was entered (e.g., January, Feb).

Enter the total amount of other income you received during the past twelve months.

Enter a narrative describing the manner of service and the persons served, including each person’s full name, role (e.g., defendant, judge, court reporter), complete address, telephone number, and any other relevant contact information and service details.

Provide the petitioner's full name followed by the complete home mailing address in a single block if you prefer to give the information together.

Enter the petitioner's full legal name as it should appear on the form.

Enter the petitioner's primary street address (house number and street name) for the home residence.

Enter any secondary address information such as apartment, suite, unit number, or other delivery details.

Enter the city of the petitioner's home mailing address.

Enter the state of the petitioner's residence (state name or postal abbreviation).

Enter the postal ZIP code for the petitioner's home address.

Enter the petitioner’s signature or printed name as their acknowledgement of the statements on this form.

Enter the date when the petitioner signs the form.

Enter the full name of the plaintiff’s or appellant’s attorney representing the party in this matter. Fill only if 'Check here if you have no attorney (Self-Represented / Pro Se Litigant)' is 'No'.

Check this box only if you have no attorney and are representing yourself (are a self-represented or Pro Se litigant).

Check this box when there is no verbatim (word-for-word) record available for the proceedings in this case.

Check this box when the complete transcript for the proceedings has been filed and lodged as part of the court record.

Enter the date on which the proof of service was signed.

Enter the street address of the person serving or the attorney, including street number and apartment or suite if applicable.

Enter the second line of the server's or attorney's address (city, state, ZIP code or suite/apartment information as needed).

Enter the telephone number where the person serving or the attorney can be reached regarding this filing, including area code.

Enter the attorney's Supreme Court identification or bar registration number, if applicable.

Enter the name of the party or client that the attorney represents in this matter.

Provide a brief description or list of additional property you own, including type and identifying details (for example: real estate, vehicles, large personal property).

Enter the total value of your stocks and bonds.

Enter any further notes or descriptive details about other property owned, such as serial numbers, addresses, or distinguishing information.

Enter the total value of any other property or assets not listed elsewhere.

Enter the total amount of cash you own in dollars and cents (numeric value; include cents and use digits only).

Enter a short descriptor for the cash being reported (for example where it is kept or the currency/type of cash).

Enter the total current dollar value of all certificates of deposit you own.

Check this box if you own or hold a checking account (and will report its current balance on the form).

Enter the current total balance held in your checking account.

Enter the vehicle manufacturer or brand (for example, Toyota, Ford, Honda).

Enter the vehicle's model year (the four-digit year of manufacture).

Enter the vehicle's purchase cost in dollars.

Enter the current outstanding amount owed on the vehicle in dollars.

Enter a brief qualifier or note related to the vehicle cost (for example, trade-in allowance, down payment, or 'N/A').

Enter a brief qualifier or note related to the amount owed on the vehicle (for example, lender name, loan type, or 'N/A').

Enter the current monetary value of the other asset you listed.

Enter a short description or name of the other property or asset you own (for example: jewelry, business interest, collectibles).

Enter the total current market value of any real estate you own (including your home and other land or buildings) as a numeric amount.

Enter the current balance of the savings account in dollars.

Enter the name of the bank, institution, or a short description identifying the savings account.

Enter a brief description of the stocks or bonds you own (such as issuer or company name and any identifying details like number of shares or bond type).

Enter the total current market value of the stocks and bonds you own in dollars.

Enter the petitioner’s signature as the official signatory for this form.

Enter the calendar date on which the petitioner signed this form.

Check this box if you are the plaintiff in this matter and, because of your financial condition, you are unable to pay the fee for filing this action.

Check this box if you cannot obtain funds from anyone, including family and associates, to pay the costs of litigation.

Check this box to confirm that the information you provide below about your ability to pay fees and costs is true and correct.

Enter the main header or caption text to appear at the top of the form (for example the case title, court caption, or other prominent heading).

Check this box when you certify that the official court reporter has informed you of the transcript's approximate length (number of pages), the per-page cost, and the total estimated cost for the transcript.

Enter the approximate number of transcript pages for this case as reported by the official court reporter. Fill only if 'Certification of transcript length and estimated cost' is 'Yes'.

Enter the reporter's charge for each transcript page. Fill only if 'Certification of transcript length and estimated cost' is 'Yes'.

Enter the total estimated cost for the transcript as provided by the official court reporter. Fill only if 'Certification of transcript length and estimated cost' is 'Yes'.

Provide the date the Notice of Appeal was filed in this matter.

Enter the full name of the person, attorney, or party submitting this transcript request.

Enter a brief description or title of the trial/hearing for which the transcript is requested (for example, 'Trial', 'Pretrial Hearing', or subject of the hearing).

Provide the date on which the trial or hearing was held.

Check this box when the caption/defendant line on the form applies to this filing or is being used to identify the defendant in this case.