Petition for Leave to Proceed In Forma Pauperis (Court of Common Pleas of Lehigh County, Pennsylvania, Civil Division) Completed Form Examples and Samples
View a completed example of the Petition for Leave to Proceed In Forma Pauperis for the Court of Common Pleas of Lehigh County, Pennsylvania (Civil Division). This filled sample and template helps you understand how to correctly complete the form to request a waiver of court fees.
Petition for Leave to Proceed In Forma Pauperis Example (Lehigh County, PA)
How this form was filled:
This example shows a completed Petition for Leave to Proceed In Forma Pauperis for an individual seeking to file a civil case in Lehigh County, PA, without paying court fees. The petitioner is unemployed, receives public assistance, has minimal assets, and their monthly expenses exceed their income, demonstrating financial hardship.
Information used to fill out the document:
- Plaintiff/Petitioner: Jane Marie Smith
- Defendant/Respondent: John P. Davis
- Docket No.: 2026-C-0123
- Petitioner's Address: 123 Maple Street, Allentown, PA 18101
- Petitioner's Telephone: (610) 555-1234
- Petitioner's Employment Status: Unemployed
- Monthly Income (Wages): $0.00
- Monthly Income (Public Benefits): $525.00 (SNAP)
- Monthly Income (Other - Unemployment): $1,200.00
- Total Monthly Income: $1,725.00
- Cash on Hand: $75.00
- Bank Account Balance: $210.00
- Real Estate Owned: None
- Vehicle Owned: 2014 Honda Civic, Value approx. $5,000
- Dependents: One (1) child, age 6
- Total Monthly Expenses: $1,850.00 (Rent, Utilities, Food, Transportation)
- Receiving Public Benefits: Yes, SNAP (Supplemental Nutrition Assistance Program)
- Date of Signature: March 15, 2026
What this filled form sample shows:
- Clear declaration of the petitioner's financial hardship, showing expenses exceed income.
- Accurate listing of all sources of monthly income, including unemployment and public benefits.
- Complete and honest disclosure of all assets, including cash, bank accounts, and personal property like a vehicle.
- Properly executed verification and signature, affirming the information is true under penalty of perjury as required by Pennsylvania law.
Form specifications and details:
| Form Name: | Petition for Leave to Proceed In Forma Pauperis |
| Jurisdiction: | Court of Common Pleas of Lehigh County, Pennsylvania, Civil Division |
| Use Case: | Individual seeking waiver of civil court filing fees and costs due to financial inability to pay. |
| Legal Basis: | Pennsylvania Rule of Civil Procedure 240 |
Created: January 29, 2026 07:35 AM
