Quiet Title An action to quiet title is a lawsuit brought in a court having jurisdiction having jurisdiction over land disputes, in order to establish a party's title to real property against anyone and everyone, and thus "quiet" any challenges or claims to the title. It comprises a complaint that the ownership (title) of a parcel of land or other real property is defective in some fashion, typically where title to to the property is ambiguous. A typical ground for complaint includes the fraudulent conveyance of a property, perhaps by a forged deed or under coercion.
Unlike acquisition through a deed of sale, a quiet title action will give the party seeking such relief no cause of action against previous owners of the property.
Court of Common Pleas of Philadelphia County Trial Division
For Prothonotary Use Only (Docket Number)
Civil Cover Sheet PLAINTIFF'S NAME
DEFENDANT'S NAME
PLAINTIFF'S ADDRESS
DEFENDANT'S ADDRESS
PLAINTIFF'S NAME
DEFENDANT'S NAME
P L A INT IF F ' S A D DRE S S
DE FE NDA NT' S A DDRES S
PLAINTIFF'S NAME
DEFENDANT'S NAME
P L A INT IF F ' S A D DRE S S
DE FE NDA NT' S A DDRES S
TOTAL NO. OF DEFENDANTS
TOTAL NUMBER OF PLAINTIFFS
AMOUNT IN CONTROVERSY
COMMENCEMENT OF ACTION
Complaint
Pet it ion Acti on
Writ of Summons
Transf er er Fr From Ot Other Ju Jur is isdicti on ons
Notice of Appeal
COURT PROGRAMS
$50,000.00 or less
Ar bi tr at i on
Mass Tort
Commerce
More than $50,000.00
Jury
Savings Action
Minor Court Appeal
Non-Jury
Pet it i on
Statutory Appeals
Settlement M i no r s W/ D/ Sur vi val
Other: CASE TYPE AND CODE (SEE INSTRUCTIONS)
STATUTORY BASIS FOR CAUSE OF ACTION (SEE INSTRUCTIONS)
RELATED PENDING CASES (LIST BY CASE CAPTION AND DOCKET NUMBER)
IS CASE SUBJECT TO COORDINATION ORDER?
Ye s
TO THE PROTHONOTARY: Kindly enter my appearance on behalf of Plaintiff/Petitioner/Appellant: Papers may be served at the address set forth below. NAME OF PLAINTIFF'S/PETITION PLAINTIFF'S/PETITIONER'S/APPELLANT'S ER'S/APPELLANT'S ATTORNEY
PHONE NUMBER
ADDRESS ( SEE S EE INSTRUCTIONS) INSTRUCTIONS)
FAX NUMBER
S U P RE M E C O URT I D E N T I F I CAT I ON N O.
E -MA IL ADDRE S S
SIGNATURE
DATE
No
Instructions for Completing Civil Cover Sheet Rules of Court require that a Civil Cover Sheet be attached to any document commencing an action (whether the action is commenced by C omplaint, Writ of Summons, Notice of Appeal, or by Petition). The information requested is necessary necessary to allow the Court to properly monitor, control and dispose cases filed. filed. A copy of the Civil Cover Sheet must be attached attached to service copies of the document commencing commencing an action. The attorney or nonrepresented party filing a case shall complete the form as follows: A.
Parties
i.
Plaintiffs/D Plaintiffs/Defenda efendants nts Enter names (last, first, first, middle initial) of plaintiff, petitioner or appellant ("plaintiff") ("plaintiff") and defendant. If the plaintiff or defendant is a government agency or corporation, use the full full name of the agency or corporation. corporation. In the event there are more more than three plaintiffs and/or three defendants, list the additional parties on the Supplemental Parties Form. Form. Husband and wife are to be listed as separate parties. parties.
ii.
Parties' Parties' Addresses Enter the address of the parties at the time of filing of the action. If any party is a corporation, enter the address of the registered registered office of the corporation.
iii. Number of of Plaintiffs/Defend Plaintiffs/Defendants: ants: Indicate the total number of plaintiffs and total number of defendants in the action. B.
C om om me me nc nc em em en en t Ty pe pe : Indicate type of document filed to commence the action.
C.
A mo mo un un t in in C on on tr tr o ov v er er ssy y:
D.
C ou ou rt rt P ro ro gr gr am am : Check the appropriate box.
E.
C as e Typ e s : Insert the code number and type of action by consulting the list set forth hereunder. To perfect a jury trial, the appropriate fees must be paid as provided by rules of court.
Check the appropriate box.
Proceedings Commenced by Appeal
Actions Commenced by Writ of Summons or Complaint
Minor Court 5 M M on on ey ey J u dg dg me me nt nt 5 L L an an dl dl or or d an an d Te Te na na nt nt 5D Denial Denial Open Open Defa Default ult Judgm Judgment ent 5 E C od od e En En fo fo rc rc em em en en t Other: Local Agency 5B Motor Motor Vehi Vehicle cle Susp Suspens ension ion Breathalizer 5V Motor Motor Vehi Vehicle cle Licens Licenses, es, Inspections, Insurance 5 C C iv iv il il Se Se rv rv ic ic e 5 K P h il il a de de l ph ph i a P ar ar k in in g A u th th o ri ri t y 5 Q L iq iq u or or C on on t ro ro l Bo Bo ar ar d 5R Board Board of of Revis Revision ion of Taxe Taxess 5 X Ta x A ss ss es es sm sm en en t B oa oa rd rd s 5 Z Z on on in in g B oa oa rd rd 5 2 B o ar ard of of Vi Vi e w 5 1 Other: Other:
Contract 1C C o n t rac t 1 T C on on st st ru ru ct ct io io n 1 O O t h e r: Tort 2B Assa Assaul ultt and and Batt Batter ery y 2L Libe Libell and and Slan Slande derr 4 F Fraud 1 J Bad Fa Faith 2E Wrongf Wrongful ul Use Use of Civil Civil Proc Process ess Other: Negligence 2V Motor Motor Vehi Vehicle cle Accid Accident ent 2H Other Other Traffi Trafficc Accide Accident nt 1F No Faul Faultt Bene Benefi fits ts 4M Motor Vehicle ehicle Property Property Damage Damage 2F Pers Person onal al Inj Injur ury y - FEL FELA A 2O Othe Otherr Perso Persona nall Injur Injury y 2S Premi Premises ses Liabil Liability ity - Slip Slip & Fall Fall 2 P P ro ro du du ct ct L ia ia bi bi li li ty ty 2 T To xi xi c To r t T1 Asbes Asbesto toss TZ D E S T 2 I mp mp la la nt nt 3 E To xi xi c Wa st st e Other:
Proceedings Commenced by Petition 8 P A pp pp o in in tm tm en en t o f A rb rb i tr tr at at or or s 8 C N am am e C ha ha ng ng e - A du du lt lt 8 L C o mp mp e l M e di di c al al E xa xa m in in a ti ti o n 8 D E mi mi ne ne nt nt Do Do ma ma in in 8 E E le le ct ct io io n M at at te te rs rs 8 F F o r f e i tu tu r e 8S Leave Leave to Issue Issue Subpo Subpoena ena 8M Mental Mental Health Health Proceed Proceedings ings 8G Civil Civil Tax Tax Cas Casee - Petit Petition ion Other:
Professional Malpractice 2 D Dental 4 L Leg al 2 M Me di cal 4 Y O t h e r: 1G Subrogation Subrogation Equity E 1 N o R ea ea l E st st at at e E 2 R ea ea l Est at ate 1D Decl Declar arat ator ory y Judgme Judgment nt M 1 M an an da damu s Real Property 3R Rent Rent,, Leas Lease, e, Eje Eject ctme ment nt Q 1 Qu ie ie t T it it le le 3F Mort Mortga gage ge For Forec eclo losu sure re 1 L M ec ec ha ha ni ni cs cs L ie ie n P 1 Pa rt i t i o n Prevent Waste 1V R e p l e v i n 1H Civil Tax Tax Case - Complaint Other:
F.
C om om me me rc rc e Pr Pr og og ra ra m Commencing January 3, 2000 the First Judicial District instituted a Commerce Program for cases involving corporations and corporate law issues, in general. If the action involves corporations as litigants or is deemed a Commerce Program case for other reasons, please check this block AND complete the information on the "Commerce Program Program Addendum". For further instructions, see Civil Trial Division Administrative Docket 01 01 of 1999.
G.
S t a tu tu t o orr y Ba Ba s i s f o r C a us us e of of A ct ct i o n If the action is commenced pursuant to statutory authority ("Petition Action"), the specific statute must be identified.
H.
R e la la te t e d P e nd nd i ng ng C as as e s All previously filed related cases, regardless of whether consolidated by Order of Court or Stipulation, must be identified.
I.
P la l a in in ti ti ff ff 's 's A tt tt or or ne ne y The name of plaintiff's attorney attorney must be inserted herein together with with other required information. In the event the filer is not represented by an attorney, the name of the filer, address, the phone number and signature is required.
The current version of the Civil Cover Sheet may be downloaded from the FJD's website http://courts.phila.gov
01-101 (Rev. 2/00) (Reverse)
NAME OF FILING PARTY:
___________________________________
Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Telephone
THIS IS NOT AN ARBITRATION CASE
___________________________________
______________________________ ___________________________ ___ ___________________________ ___ ______________________________ Plaintiff vs. ______________________________ ______________________________ Defendant
: : : : : : : : : : :
PHILADELPHIA COUNTY COURT OF COMMON PLEAS TRIAL DIVISION - CIVIL
_________ TERM, _____________ Month
Year
No. ________________________
ACTION TO QUIET TITLE (FRAUDULENT CONVEYANCE) NOTICE
AVISO
You have have been sued sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after the complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested requested by plaintiff. plaintiff. You may lose money money or or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND FIND OUT WHEREYOU CAN GET LEGAL HELP.
Le han demandado a usted en la corte. Si usted quiere quiere defenderse de estas demandas expuestas en las páginas siguientes, usted tiene veinte (20) dias de plazo al partir de la fecha de la demanda y la notificatión. notificatión. Hace falta asentar una com comparencia parencia escrita escrita o en persona o con un abogado y entregar a la corte en forma escrita sus defensas o sus objeciones a las demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomará medidas y puede continuar la demanda en contra suya sin previo aviso o notificación. notificación. Además, la corte puede decider a favor del demandante demandante y requiere que usted cumpla con todas las provisiones de esta demanda. Usted puede perder dinero o sus propiedades u otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE. INMEDIATAMENTE. SI NO TIENE ABOGADO O SI SI NO TIENE TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ESCRITA ABAJO PARA AVERIGUAR DONDE SE SE PUEDE CONSEGUIR ASISTENCIA LEGAL.
PHILADELPHIA BAR ASSOCIATION Lawyer Lawyer Referral and Information Service 1101 Market Market Street, 11th Floor Philadelphia, Pennsylvania Pennsylvania 19107 (215) 238-1701
ASOCIACIÓN DE LICENCIADOS DE FILADELFIA Servicio De Referencia E Información Legal 1101 Market Street, 11th Floor Filadelfia, Pennsylvania 19107 (215)238-1701
1
NAME OF FILING PARTY:
___________________________________
Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Telephone
THIS IS NOT AN ARBITRATION CASE
___________________________________
______________________________ ___________________________ ___ ___________________________ ___ ______________________________ Plaintiff vs. ______________________________ ______________________________ Defendant
: : : : : : : : : : :
PHILADELPHIA COUNTY COURT OF COMMON PLEAS TRIAL DIVISION - CIVIL
_________ TERM, _____________ Month
Year
No. ________________________
ACTION TO QUIET TITLE (FRAUDULENT CONVEYANCE)
Plaintiff, hereby files this Complaint against the Defendant to Quiet Title with respect to a certain parcel of real estate and in support thereof avers as follows:
1. Plaintiff(s) is/are: _______________________________________________________________ _______________________________________________________________
2. Defendant(s) is/are: _______________________________________________________________ _______________________________________________________________
2
3. The real estate, which is the subject of this litigation is:
_______________________________________________________________ _______________________________________________________________ ______________________________________________________________. A copy of the legal description is contained within the deed conveying the property to the Plaintiff, which is attached hereto.
4. State the cause of action in detail: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
3
WHEREFORE, Plaintiff respectfully requests that this Honorable Court find in
his/her favor and against the Defendant(s), and enter a judgment ordering the Recorder of Deeds for Philadelphia County to convey the property located at: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ to the Plaintiff(s), upon presentment of an order stating the same; and granting such other relief as is necessary and appropriate.
Respectfully submitted:
__________________________________ Plaintiff
___________________________________ Plaintiff
Date: _______________________
4
NAME OF FILING PARTY:
___________________________________
Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Telephone
___________________________________
______________________________ ___________________________ ___ ___________________________ ___ ______________________________ Plaintiff vs. ______________________________ ______________________________ Defendant
: : : : : : : : : : :
PHILADELPHIA COUNTY COURT OF COMMON PLEAS TRIAL DIVISION - CIVIL
_________ TERM, _____________ Month
Year
No. ________________________
AFFIDAVIT OF PLAINTIFF COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA
: : :
ss.
I, _____________________________ (Plaintiff), being duly sworn according to law, depose and say that the facts stated herein are true and correct.
________________________________ Plaintiff
__________________________________ Plaintiff
5
VERIFICATION
Plaintiff(s)_________________________________________________________ ________________________________________________________________________ hereby verify that the statements set forth in the foregoing Complaint are true and correct to the best of my knowledge, information, and belief; I understand that these statements are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.
_________________________________ Signature of Plaintiff
__________________________________ Signature of Plaintiff
Dated: _____________________
6
MOTION TO PROCEED IN FORMA PAUPERIS
PHILADELPHIA COURT OF COMMON PLEAS
CONTROL NUMBER:
PETITION/MOTION COVER SHEET FOR COURT USE ONLY
(RESPONDING PARTIES MUST INCLUDE THIS NUMBER ON ALL FILINGS)
ANSWER/RESPONSE DATE:
ASSIGNED TO JUDGE:
Term,
Do not send Judge courtesy copy of Petition/Motion/Answer/Response. Status may be obtained online at http://courts.phila.gov
Month
Ye a r
No. Name of Filing Party:
vs .
INDICATE NATURE OF DOCUMENT FILED: Petition (Attach Rule to Show Cause) Motion A ns w er to P eti tio n R esp ons e t o M otio n
(Check one) (Check one)
Plaintiff Movant
D ef e n d a n t R es po n den t
Has another petition/motion been decided in this case?
Yes
No
Is another petition/motion pending? Yes If the answer to either question is yes, you must identify the judge(s):
No
TYPE OF PETITION/MOTION (see list on reverse side)
PETITION/MOTION CODE (see list on reverse side)
MOTION TO PROCEED IN FORMA PAUPERIS
MTIFP
ANSWER/RESPONSE FILED TO (Please insert the title of the corresponding petition/motion petition/motion to which you are responding):
I. CA CASE SE PR PROG OGRA RAM M Is this case in the (answer all questions) : A. COM COMMERC MERCE E PROGRAM PROGRAM
II. PARTIES (Name, address and telephone number of all counsel of record and unrepresented parties. Attach a stamped addressed envelope for each attorney of record and unrepresented party.)
Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes
No
B . DAY FORWARD FORWARD/MAJ /MAJOR OR JURY JURY PROGRAM PROGRAM — Year Name of Judicial Team Leader: Applicable Petition/Motion Deadline: Has deadline been previously extended by the Court? Yes
No
C . NON JURY JURY PROG PROGRAM RAM Date Listed: D. ARBITR ARBITRATION ATION PROGR PROGRAM AM Arbitration Date: E. ARBI ARBITRAT TRATION ION APPEAL APPEAL PROGRAM PROGRAM Date Listed: F. OTH OTHER ER PRO PROGRA GRAM: M: Date Listed: III. OTHER
By filing this document and signing below, the moving party certifies that this motion, petition, answer or response along with all documents filed, will be served upon all counsel and unrepresented parties as required by rules of Court (see PA. R.C.P. 206.6, Note to 208.2(a), and 440). Furthermore, moving party verifies that the answers made herein are true and correct and understands that sanctions may be imposed for inaccurate or incomplete answers.
(A tto r ne y Si gnat ur e /Un re p re s e nt e d P ar ty )
(Date)
( P r int Nam e )
( A t to r ne y I . D. No . )
The Petition, Motion and Answer or Response, if any, will be forwarded to the Court after the Answer/Response Date. No extension of the Answer/Response Date will be granted even if th e parties so stipulate. 30-1061A (Rev. 7/05)
Instructions for completing Petition to Proceed In Forma Pauperis 1. All blanks blanks and all all questions questions MUST be filled filled in or answered. answered. Dollar amounts MUST be clearly stated where requested. 2. A copy of your your latest latest Pennsylvani Pennsylvania a tax or federal federal tax tax return should be attached. 3. Service of of a copy of of this petition petition MUST MUST be made made on the opposing party or opposing party’s attorney. 4. Please attach a self-addr self-addressed, essed, stamped stamped envelope envelope for for yourself and an addressed, stamped envelope for each opposing party or opposing party’s attorney. 5. Petitioner Petitioner is required required to have have the enclosed enclosed Affidavit Affidavit notarized notarized by a licensed Notary Public. 6. Your petition petition may may be dismissed dismissed or denied denied for failure failure to properly complete all information.
Definition of Terms: Affidavit: A voluntary declaration of facts written down and sworn to by the declarant before an
officer authorized to administer oaths. Defendant: A person who is sued in a civil or criminal proceeding. In Forma Pauperis: [Latin “in the manner of a pauper”] To proceed in the manner of an
indigent who is permitted to disregard filing fees and court costs. Petitioner: A party who presents a petition to a court or other official body. Plaintiff : The party who brings a civil suit in a court of law against another person or entity.
First Judicial District of Pennsylvania Court of Common Pleas of Philadelphia County Civil Trial Division ___________________________________, pro se (your name)
___________________________________ ___________________________________ (full address)
___________________________________ (area code and telephone number)
____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ ___________________________________ Plaintiff(s) VS.
___________________________________ ____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ Defendant(s)
: : : : : : : : : : :
____ ______ ____ ____ ____ ____ ____ ____ ____ ___T _Ter erm, m, 20__ 20____ ____ ____ ___ _ (month)
(year)
NO._ NO.___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ __
In Forma Pauperis Order AND NOW, this ____________day ____________day of ______________________ ________________________, __, 20_______ , it is hereby ORDERED AND DECREED that: 1. Petitioner Petitioner be permitted permitted to proceed without without paying the the costs of this this proceeding proceeding or
posting a bond. 2. Petitioner Petitioner be permitted permitted to obtain service of the papers papers filed without without cost. cost. 3. Petitioner be permitted to proceed in forma pauperis as to any additional costs
which accrue in the course of this proceeding. (IFP/REV.10/2000)
Cour t Ter m_________ m____________ ______ ____20_ _20____ ___an an d No._______ No.___________ ____
4. If there is a monetary recovery by judgment or settlement in favor of the party
permitted to proceed in forma pauperis , the exonerated fees and costs shall be taxed as costs and paid to the Prothonotary by the party paying the monetary recovery. Petitioner has a contin continuing uing oblig obligatio ation n to inform inform the Court of any improvem improvement ent in party’s party’s 5. Petitioner financial circumstances that will enable the party to pay costs.
BY THE COURT:
________________________________________ J.
Page 2 of 11
First Judicial District of Pennsylvania Court of Common Pleas of Philadelphia County Civil Trial Division __________________________________, pro se (your name)
__________________________________ __________________________________ (full address)
__________________________________ (area code and telephone number)
____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ __
____ ________ ________ _______ ________ ________ _______ _____ Plaintiff(s) VS. __ _____ _____ ____ _____ _____ ___ __ _____ _____ ____ _____ _____ ___ Defendant(s)
: : : : : : : : : : : :
____ ______ ____ ____ ____ ____ ____ ____ ___, _, TERM TERM,, 20 ____ ______ __ (month)
(year)
NO. _____________________________
Petition to Proceed In Forma Pauperis and Without Payment of Bond TO THE HONORABLE, THE JUDGES OF SAID COURT:
Petitioner, ( your your name) _________________________________________, seeks (please print your name)
leave to proceed in this matter in forma pauperis, and respectfully represents that: 1. I am the (indicate plaintiff or defendant ) __________________________ in these
proceedings. Court Term__________________20____and No. ________
Page 3 of 11
2. I reside at (state your full address) ______________________________________________
______________________________________________________________________________ ______________________________________________________________________________ 3. I have listed my sources and amounts of income truly and correctly on the
attached affidavit. following average monthly expenses for for the indicated items: items: 4. I have the following
Housing: __________________
Insurance:
Utilities:
___ ____ _____ _____ _
Transportation:
(Gas):
___ ____ _____ _____ _
Medical:
_ ____ _____ _____ ____ _
(Oil):
___ ____ _____ _____ _
Loans:
_ ____ _____ _____ ____ _
(Electric):__________________
Laundry:
_ ____ _____ _____ ____ _
(Phone): __________________
Child Ca C are:
_ ____ _____ _____ ____ _
F ood :
__ _____ ____ _____ __
_ ____ _____ _____ ____ _ _ _____ _____ _____ __
Child Support: ____________________
Clot Clothi hing ng:: _____ ________ _____ _____ _____ _____ ___
assets other than the following following (state values in 5. I neither own nor have equity in any assets dollars): ____________________________________________________________________
___________________________________________________________________________ obtain the amount of costs 6. I am unable to pay the costs of these proceedings or to obtain from family or friends.
Page 4 of 11
Court Term__________________20____and No. ________
WHEREFORE, Petitioner prays that he/she be permitted to proceed in this matter in forma pauperis and without the payment of bond.
_______________________________________ (Print your name) Petitioner
_______________________________________ (Sign your name) Petitioner
Page 5 of 11
First Judicial District of Pennsylvania Court of Common Pleas of Philadelphia County Civil Trial Division
____________________ ______________________________ ________________, ______, pro se (your name)
____________________________________ ____________________________________ (full address)
____________________________________ (area code and telephone number)
____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ ____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ Plaintiff(s)
VS. ____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ ____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ _ Defendant(s)
: : : : : : : : : : : :
____ ______ ____ ____ ____ ____ ____ ____ ____ ____ ____ __ TERM TERM,, 20__ 20____ __ (Month)
(Year)
NO. _______________________________
Petitioner’s Affidavit Pursuant to PA. R.C.P. 240 COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA
: : :
SS.
_________________________________________, _________, am the (Plaintiff) (Defendant) 1. I, ________________________________ (circle one)
in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding.
Page 6 of 11
to obtain funds from anyone, including including my family and associates, to pay 2. I am unable to the costs of litigation. information below relating relating to my ability ability to pay the fees and costs 3. I represent that the information is true and correct: (a) Name: _______________ _______________________ ________________ _______________ _______________ _______________ _______________ ________________ ________ Address: Address: _______________ ______________________ _______________ ________________ _______________ _______________ ________________ _____________ _____ __________________________________________________________________ Social Security #_____________________________________________________________ (b) EMPLOYMENT If you are presently employed, state:
Employer :
____________________________________________________ ________________________ _______________________________________ ___________
Addr Addres ess: s:
_____ ________ _____ _____ ______ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ __ _______________________________________________________________
Salary/wages Per Month: Month: ________ ____________ ________ _______ _______ ________ ________ ________ ________ _______ _______ ________ ________ ________ _______ ____ _ Type of Work: ______________________________________________________________ If you are presently unemployed, state:
Date Date of last last Employ Employmen ment: t:
_______ ___________ ________ ________ ________ ________ _______ _______ ________ ________ ________ _______ ____ _
Salary/Wages Per Month: Month: ________ ____________ ________ _______ _______ ________ ________ ________ ________ _______ _______ ________ ________ ________ _______ ____ _ Type of Work:______________________________________________________________ (c) OTHER INCOME WITHIN THE PAST TWELVE (12) MONTHS (state as dollar amounts) Business or Profession:_______________________________________________________ Other Self-employ Self-employment: ment: ________________ _______________________ _______________ _______________ _______________ _______________ _______
Page 7 of 11
Interest:___________________________________________________________________ Dividends:_________________________________________________________________ Pension and Annuities:________________________________________________________ Social Security Benefits:_______________________________________________________ Support Payments:___________________________________________________________ Disability Payments:_________________________________________________________ Unemployment Compensation & Supple Supplemen mental tal Benefi Benefits: ts: ________ ____________ ________ _______ _______ ________ ________ ________ _______ _______ ________ ________ _______ ___ Workmans’ Compensation: ____________________________________________________ Public Assistance:____________________________________________________________ Other:_____________________________________________________________________ (d) OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT (state as dollar amounts) (Wife) (Husband) (Friend) Name:_______________________________________________ If your (wife) (husband) (friend) is employed, state:
Employer: Employer: _______________ ______________________ _______________ ________________ _______________ _______________ ________________ ____________ ____ Salary/Wages Per Month: Month: ________ ____________ ________ _______ _______ ________ ________ ________ ________ _______ _______ ________ ________ ________ _______ ____ _ Type of Work:______________________________________________________________ Contributions From Children: _____________________________________________________________ Contributions From Parents: Parents: ________________ _______________________ _______________ ________________ _______________ _______________ _______________ ________ _ Other Contributions:__________________________________________________________
(e) PROPERTY OWNED (state as dollar amounts) Cash:______________________________________________________________________
Page 8 of 11
Checking Account:___________________________________________________________ Savings Account:____________________________________________________________ Certificates of Deposit:________________________________________________________ Real Estate (Including Home): ___________________________________________________________ Motor Vehicle: Make _______________________________ Cost $_________________________ $_________________________________ ________
Year __________________
Amount Owed Z
Stocks & Bonds: ____________________________________________________________ Other: Other: _______________ _______________________ ________________ _______________ _______________ _______________ _______________ ________________ ________ _____________________________________________________________________
(f) DEBTS AND OBLIGATIONS (state as dollar amounts) Mortgage: Mortgage: _______________ ______________________ _______________ ________________ _______________ _______________ ________________ _____________ _____ Rent Rent::
_____ _______ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ ___
Loans: Loans:
_______ ___________ ________ ________ _______ _______ ________ ________ ________ ________ _______ _______ ________ ________ ________ _______ _____ __
Othe Other: r:
_____ _______ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ ___
(g) PERSONS DEPENDENT UPON YOU FOR SUPPORT (Wife) (Husband) Name: ______________________________________________________ Children Children,, if any: _______________ ______________________ _______________ ___________Age ___Age ______________ ______________________ _________ _ _________________________________Age _______________________ _________________________________Age _______________________ _________________________________Age _______________________ Other Persons: Name:_________________________________________________________________
Page 9 of 11
Relationship Relationship:: _______________ _______________________ _______________ _______________ ________________ _______________ ____________ _____
obligation to inform inform the Court of improvement in my 4. I understand that I have a continuing obligation financial circumstances which would permit me to pay the costs incurred herein. statements made in this affidavit are true and correct. correct. I understand that false 5. I verify that the statements statements herein are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities.
Date Dated: d: _____ ________ ______ _____ _____ _____ ____ __
____ _______ ______ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ ____ __ ( Print Petitioner Print your name)
__________________________________________ Petitioner (Sign your name)
Sworn to and subscribed before me this ______ day of ______________,20______. __________________________________ Notary Public
Page 10 of 11
Certificate of Service I hereby certify that I have served a copy of this petition upon all other parties or their attorney of record by: Please check:
Regular First Class Mail Certified Mail Other
Name of Petitioner
Signature of Petitioner
Dated: ________________________
Page 11 of 11
(Print Name)
(Sign your name)
