Section 561. Form of IFP Verified Statement

A verified statement under this chapter in support of an application for leave to proceed in forma pauperis shall be in substantially the following form:

[Caption]

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states under the penalties provided by

(Insert name of applicant)

18 Pa.C.S. 4904 (unsworn falsification to authorities) that:

1. I am the

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in the above action and because of (plaintiff or defendant)
my financial condition am unable to pay the following fees and costs:

(state with particularity the relief requested, e.g., appellate filing fees, costs of reproducing records or briefs, or filing of supersedeas security if irreparable harm would result if not waived.)

2. My responses to the questions below relating to my ability to pay the fees and costs of prosecuting an appeal are true and correct.

(a) Are you presently employed?

(1) If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.

(2) If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received.

(b) Have you received within the past twelve months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest, dividends, pensions, annuities, social security benefits, support payments or other source?

If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months.

(c) Do you own any cash or checking or savings account?

If the answer is yes, state the total amount of the items owned.

(d) Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?

If the answer is yes, describe the property and state its approximate value and the amount of any encumbrances.

(e) List the persons, if any, who are dependent upon you for support and state your relationship to those persons.

(f) List all your debts and obligations.

3. I understand that a false statement or answer to any question in this verified statement will subject me to the penalties provided by law (misdemeanor of the second degree).

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Signature of Applicant

Note

:Extends former Supreme Court Rule 61 (form) to the Superior and Commonwealth Courts and makes no change in substance other than the substitution of the statutory verification for an affidavit.

The provisions of this Rule 561 amended February 27, 1980, 10 Pa.B. 1038, effective date as set forth at 10 Pa.B. 1038. Immediately preceding text appears at serial page (25387).