Petition for Leave to Proceed In Forma Pauperis (Court of Common Pleas of Lehigh County, Pennsylvania, Civil Division) Instructions
This form contains 65 fields organized into 23 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Name (Financial Information Section) | ||
| Applicant Name | Text |
Enter the full name of the applicant (plaintiff or defendant) as it should appear on the petition.
|
| Case Caption (Plaintiff, Defendant, File Number) | ||
| Plaintiff Name | Text |
Enter the full name of the plaintiff as it should appear on the court caption (include any business or trade names if applicable).
|
| Defendant Name | Text |
Enter the full name of the defendant as it should appear on the court caption (include any business or trade names if applicable).
|
| File Number | Text |
Enter the court file/case number assigned to this matter as it appears on official court documents.
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| Contact Information | ||
| Address | Text |
Enter your full mailing address (street address, apartment or unit if applicable, city, state/province, and ZIP/postal code) as a single line.
|
| Phone Number | Text |
Enter your primary telephone number where you can be reached, including area code and any required country or city prefixes.
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| Current Employment Details | ||
| Current Employer | Text |
Enter the full name of your current employer or company for whom you work.
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| Employer Address | Text |
Enter the employer's full mailing address, including street, city, state/province and ZIP/postal code.
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| Salary or Wages Per Month | Number |
Provide your current gross salary or wages per month from this employment.
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| Types of Work | Text |
Describe the types of work you perform in this job, including your job title and main duties.
|
| Date | ||
| Date | Date |
Enter the date when the petitioner signs or files this document.
|
| Debts and Obligations | ||
| Mortgage payment | Number |
Enter the mortgage payment amount you are obligated to pay for your residence.
|
| Rent payment | Number |
Enter the rent amount you pay for housing, if applicable.
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| Loan payments | Number |
Enter the total amount of your regular loan payments (for example, auto, student, or personal loans).
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| Other debts/obligations | Number |
Enter the amount for any other recurring debts or obligations not listed above (for example, credit card minimums, alimony, or child support).
|
| Total debts and obligations | Number |
Enter the combined total amount of all debts and obligations listed above.
|
| First Child Dependent | ||
| First Dependent Name | Text |
Enter the full name of your first child who is dependent upon you for support.
|
| First Dependent Age | Text |
Enter the current age in years of your first child dependent.
|
| General | ||
| v | Text | |
| w | Text | |
| nn | Text | |
| oo | Text | |
| Signature1 | Signature | |
| Income Sources (Workers' Comp, Public Assistance, Other) | ||
| Workers' compensation | Number |
Enter the amount of workers' compensation income you receive to report for this application period.
|
| Public assistance | Number |
Enter the amount of public assistance (e.g., TANF, general assistance) you receive to report for this application period.
|
| Other income or source details | Text |
Describe any other income source(s) or provide details about other assistance you receive that are not listed above.
|
| Other (Previous Section) | ||
| Other — Details | Text |
Provide a brief description of any other information, item, or circumstance not captured in the previous sections that is relevant to this form.
|
| Other Dependent Persons | ||
| Other persons (count or brief list) | Text |
Enter the number of other persons dependent on you or a short listing/identifier of those persons you are reporting here.
|
| Other person Name | Text |
Enter the full name of the other dependent person you are listing.
|
| Other person Relationship | Text |
Enter the relationship of the named person to you (for example: friend, parent, sibling, roommate, etc.).
|
| Other Household Support Contributions (Children, Parents, Other) | ||
| Contributions from children | Number |
Enter the total amount contributed by your children toward household support.
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| Contributions from parents | Number |
Enter the total amount contributed by your parents toward household support.
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| Other contributions to household support | Number |
Enter the total amount of any other contributions toward household support not listed above.
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| Other Income in Past Twelve Months | ||
| Business or profession income | Number |
Enter the total income you received from your business or profession within the past twelve months.
|
| Other self-employment income | Number |
Enter the total income you received from other self-employment or freelance work within the past twelve months.
|
| Interest income | Number |
Enter the total interest income you received (for example from savings, bonds, or loans) within the past twelve months.
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| Dividend income | Number |
Enter the total dividends you received from investments within the past twelve months.
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| Pension and annuities | Number |
Enter the total pension and annuity payments you received within the past twelve months.
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| Social Security benefits | Number |
Enter the total Social Security benefits you received within the past twelve months.
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| Support payments | Number |
Enter the total support payments (such as alimony or child support) you received within the past twelve months.
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| Disability payments | Number |
Enter the total disability payments you received within the past twelve months.
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| Unemployment compensation and supplemental benefits | Number |
Enter the total unemployment compensation and any supplemental unemployment benefits you received within the past twelve months.
|
| Petitioner Name | ||
| Petitioner Name | Text |
Enter the full legal name of the petitioner (the person or party filing this petition) exactly as it should appear on court records.
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| Petitioner Phone Number | ||
| Petitioner Phone Number | Text |
Enter the petitioner's telephone number, including area code and any extension if applicable (for example: (555) 123-4567 or 555-123-4567 ext. 89).
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| Property Owned - Cash and Accounts | ||
| Cash on hand | Number |
Enter the total amount of cash you currently have on hand.
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| Checking account balance | Number |
Enter the current balance in your checking account.
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| Savings account balance | Number |
Enter the current balance in your savings account.
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| Certificates of deposit (CDs) value | Number |
Enter the total value of any certificates of deposit (CDs) you own.
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| Property Owned - Motor Vehicle Details | ||
| Motor vehicle - Make | Text |
Enter the vehicle's manufacturer and model or identifying make (for example, "Toyota Camry").
|
| Motor vehicle - Year | Number |
Enter the vehicle's model year.
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| Motor vehicle - Cost | Number |
Enter the purchase cost or current value of the vehicle.
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| Motor vehicle - Amount Owed | Number |
Enter the outstanding loan or amount still owed on the vehicle.
|
| Property Owned - Stocks and Bonds | ||
| Stocks and bonds (total value) | Number |
Enter the total current market value of all stocks and bonds you own as a numeric amount.
|
| Second Child Dependent | ||
| Second Child Name | Text |
Enter the full name of the second child dependent as you want it recorded (first and last name).
|
| Second Child Age | Text |
Enter the current age of the second child dependent in years.
|
| Spouse/Partner Dependent Name | ||
| Spouse/Partner Name | Text |
Enter the full name of your spouse or domestic partner (e.g., first, middle initial, and last name) as the person dependent upon you for support.
|
| Spouse/Partner Employment Information | ||
| Spouse/Partner Name | Text |
Enter the full name of your spouse or partner (first and last name) as it should appear on the form.
|
| Employer | Text |
Enter the name of the company or employer where your spouse or partner is currently employed.
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| Monthly Salary or Wages | Number |
Enter the amount your spouse or partner earns per month in salary or wages.
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| Type of Work | Text |
Describe the spouse or partner's job title or primary type of work or duties (for example, teacher, cashier, mechanic).
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| Third Child Dependent | ||
| Third Child — Name | Text |
Enter the full name of the third child dependent as it should appear on the form.
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| Third Child — Age | Text |
Enter the current age of the third child dependent in years.
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| Unemployment / Last Employment Details | ||
| Date of Last Employment | Date |
Enter the date you last worked for your previous employer (the last day or month/year of that employment).
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| Last Monthly Salary or Wages | Number |
Enter the amount you were paid per month at your last employment (the monthly salary or wages).
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| Type of Work at Last Employment | Text |
Describe the job title or type of work you performed at your most recent employment.
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