COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.IN THE COURT OF COMMON PLEAS OF INDIANA COUNTY, PENNSYLVANIA,:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Plaintiff,:vs.: NO.C.D.,:CIVIL ACTION -LAWDefendant. :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AFFIDAVIT AND PETITION TO PROCEED IN FORMA PAUPERIS 1. I am the 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. 2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation. 3. I represent that the information below relating to my ability to pay the fees and costs is true and correct:THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of(a)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomName: Address: Social Security Number: (b)Employment:If you are presently employed, state: Employer: Address: Salary or wages per month: Type of work: If you are presently unemployed, state Date of last employment: Salary or wages per month: Type of work: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)(c)Other income within the past twelve months: Business or profession: Other self-employment: Interest: Dividends: Pension and annuities: Social security benefits: Support payments: Disability payments: Unemployment compensation and supplemental benefits: Workman's compensation: Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Public assistance: Other: (d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other contributions to household support: Spouse's Name: If your spouse is employed, state Employer: Salary or wages per month: Type of work: Contributions from children: Contributions from parents: Other contributions: (e)THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomProperty owned: Cash: Checking account: Savings account: Certificates of Deposit: Real estate (including home): Motor vehicle: Make , Year , Cost , Amount Owed $ Stocks; bonds: Other: (f)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Debts and Obligations: Mortgage: Rent: Loans: Other: (g)Persons dependant upon you for support: Spouses Name: Children, if any: , one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Age: Name: Attorney(s) forOther persons: Name: Relationship: Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:4. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances which would permit me to pay the costs incurred herein. 5. I verify that the statements made in this affidavit are trueMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. section 4904, relating to unsworn falsification to authorities.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Date:Petitioner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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