Quiet Title

An action to quiet title is a lawsuit brought in a court having

Filed and Attested by

PROTHONOTARY
12 AUG 2014 08:42 pm
jurisdictionK.over
EDWARDS

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 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.

Case ID: 140801554

Court of Common Pleas of Philadelphia County

Trial Division
PLAINTIFF'S NAME

For Prothonotary Use Only (Docket Number)

Civil Cover Sheet

DEFENDANT'S NAME

Jaeziel Vasquez

Brenda L Davila

PLAINTIFF'S ADDRESS

DEFENDANT'S ADDRESS

3212 Hooly Rd

4818 Griscom Street

Philadelphia

Pa

19154-0000

Philadelphia

PLAINTIFF'S NAME

Pa

19124-0000

DEFENDANT'S NAME

Pa Housing And Credit Solutions

Wells Fargo Bank Na

PLAINTIFF'S ADDRESS

DEFENDANT'S ADDRESS

3212 Holy Rd

3476 Stateview Blvd

Philadelphia

pa

19154-0000

Fort mill

PLAINTIFF'S NAME

sc

29715-0000

NJ

07092-0000

DEFENDANT'S NAME

Zucker, Goldberg & Ackerman

PLAINTIFF'S ADDRESS

DEFENDANT'S ADDRESS

200 Sheffield st
Mountainside
TOTAL NO. OF DEFENDANTS

TOTAL NUMBER OF PLAINTIFFS

AMOUNT IN CONTROVERSY

COMMENCEMENT OF ACTION

Complaint

Petition Action

Writ of Summons

Transfer From Other Jurisdictions

Notice of Appeal

COURT PROGRAMS

$50,000.00 or less

Arbitration

Mass Tort

Commerce

More than $50,000.00

Jury

Savings Action

Minor Court Appeal

Minors

Non-Jury

Petition

Statutory Appeals

W/D/Survival

Settlement

Other:
CASE TYPE AND CODE (SEE INSTRUCTIONS)

Q1

Quiet Title Action

STATUTORY BASIS FOR CAUSE OF ACTION (SEE INSTRUCTIONS)

RELATED PENDING CASES (LIST BY CASE CAPTION AND DOCKET NUMBER)

IS CASE SUBJECT TO
COORDINATION ORDER?

Yes

No

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/PETITIONER'S/APPELLANT'S ATTORNEY

PHONE NUMBER

ADDRESS (SEE INSTRUCTIONS)

FAX NUMBER

SUPREME COURT IDENTIFICATION NO.

E-MAIL ADDRESS

SIGNATURE

DATE

Case ID: 140801554

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 Complaint,
Writ of Summons, Notice of Appeal, or by Petition). The information requested is necessary to allow the Court to properly monitor, control and
dispose cases filed. A copy of the Civil Cover Sheet must be attached to service copies of the document commencing an action. The attorney or nonrepresented party filing a case shall complete the form as follows:
A.

Parties
i.

Plaintiffs/Defendants
Enter names (last, first, middle initial) of plaintiff, petitioner or appellant ("plaintiff") and defendant. If the plaintiff or defendant is a
government agency or corporation, use the full name of the agency or corporation. In the event there are more than three plaintiffs and/or
three defendants, list the additional parties on the Supplemental Parties Form. Husband and wife are to be listed as separate parties.

ii.

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 office of
the corporation.

iii. Number of Plaintiffs/Defendants: Indicate the total number of plaintiffs and total number of defendants in the action.
B.

Commencement Type: Indicate type of document filed to commence the action.

C.

Amount in Controversy: Check the appropriate box.

D.

Court Program: Check the appropriate box.

E.

Case Types: 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.
Proceedings Commenced by Appeal

Actions Commenced by Writ of Summons or Complaint

Minor Court
5 M Money Judgment
5 L Landlord and Tenant
5D Denial Open Default Judgment
5 E Code Enforcement
Other:
Local Agency
5B Motor Vehicle Suspension Breathalizer
5V Motor Vehicle Licenses,
Inspections, Insurance
5C Civil Service
5K Philadelphia Parking Authority
5Q Liquor Control Board
5R Board of Revision of Taxes
5X Tax Assessment Boards
5 Z Zoning Board
5 2 Board of View
5 1 Other:
Other:

Contract
1C Contract
1 T Construction
1O Other:
To r t
2B Assault and Battery
2 L Libel and Slander
4F Fraud
1J Bad Faith
2 E Wrongful Use of Civil Process
Other:
Negligence
2V Motor Vehicle Accident
2H Other Traffic Accident
1F No Fault Benefits
4 M Motor Vehicle Property Damage
2F Personal Injury - FELA
2O Other Personal Injury
2S Premises Liability - Slip & Fall
2 P Product Liability
2 T Toxic Tort
T1 Asbestos
TZ DES
T2 Implant
3 E Toxic Waste
Other:

Proceedings Commenced by Petition

8 P Appointment of Arbitrators
8C Name Change - Adult
8 L Compel Medical Examination
8D Eminent Domain
8 E Election Matters
8F Forfeiture
8S Leave to Issue Subpoena
8 M Mental Health Proceedings
8G Civil Tax Case - Petition
Other:

Professional Malpractice
2D Dental
4 L Legal
2 M Medical
4Y Other:
1G Subrogation
Equity
E 1 No Real Estate
E 2 Real Estate
1D Declaratory Judgment
M 1 Mandamus
Real Property
3R Rent, Lease, Ejectment
Q1 Quiet Title
3F Mortgage Foreclosure
1 L Mechanics Lien
P 1 Partition
Prevent Waste
1V Replevin
1H Civil Tax Case - Complaint
Other:

F.

Commerce Program
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 Addendum". For further instructions, see Civil Trial Division Administrative Docket 01 of 1999.

G.

Statutory Basis for Cause of Action

If the action is commenced pursuant to statutory authority ("Petition Action"), the specific statute must be identified.

H.

Related Pending Cases

All previously filed related cases, regardless of whether consolidated by Order of Court or Stipulation, must be identified.

I.

Plaintiff's Attorney
The name of plaintiff's attorney must be inserted herein together 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
Case ID: 140801554
01-101 (Rev. 2/00) (Reverse)

NAME OF FILING PARTY:

Terrance
Rodriguez (Filing USA)
___________________________________
Name

7311
Oxford Ave
___________________________________
Address

Philadelphia,
Pa 19111
___________________________________
City, State, Zip

8778237924
ext 201
___________________________________
Telephone

THIS IS NOT AN
ARBITRATION CASE

___________________________________

Jaeziel Vasquez
______________________________
Pa Housing And Credit Solutions
______________________________
Plaintiff

vs.
Wells Fargo Bank NA
______________________________
Zucker, Goldberg & Ackerman
______________________________
Defendant

:
:
:
:
:
:
:
:
:
:
:

PHILADELPHIA COUNTY
COURT OF COMMON PLEAS
TRIAL DIVISION - CIVIL

_________ TERM, _____________

Month

Year

No. ________________________

ACTION TO QUIET TITLE

(FRAUDULENT CONVEYANCE)
NOTICE

AVISO

You have been 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 by plaintiff. You may lose money 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 OUT WHERE YOU CAN GET LEGAL HELP.

Le han demandado a usted en la corte. Si usted quiere

defenderse de estas demandas expuestas en las pginas siguientes,
usted tiene veinte (20) dias de plazo al partir de la fecha de la demanda
y la notificatin. Hace falta asentar una comparencia 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 tomar medidas y
puede continuar la demanda en contra suya sin previo aviso o
notificacin. Adems, la corte puede decider a favor del 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.
SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE
DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR
TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA
ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE
CONSEGUIR ASISTENCIA LEGAL.

PHILADELPHIA BAR ASSOCIATION

Lawyer Referral and Information Service
1101 Market Street, 11th Floor
Philadelphia, Pennsylvania 19107
(215) 238-1701

ASOCIACIN DE LICENCIADOS DE FILADELFIA

Servicio De Referencia E Informacin Legal
1101 Market Street, 11th Floor
Filadelfia, Pennsylvania 19107
(215) 238-1701

Case ID: 140801554

NAME OF FILING PARTY:

Terrance Rodriguez (Filing USA)
___________________________________
Name

7311 Oxford Ave

___________________________________
Address

Philadelphia, Pa 19111
___________________________________
City, State, Zip

8778237924 ext 201

___________________________________
Telephone

THIS IS NOT AN
ARBITRATION CASE

___________________________________

Jaeziel Vasquez
______________________________
Pa Housing And Credit Solutions
______________________________
Plaintiff

vs.
Wells Fargo Bank NA
______________________________
Zucker, Goldberg & Ackerman
______________________________
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:
Jaeziel Vasquez
_______________________________________________________________
Pa Housing And Credit Solutions
_______________________________________________________________

2. Defendant(s) is/are:
Wells Fargo Bank NA
_______________________________________________________________
Zucker, Goldberg & Ackerman
_______________________________________________________________

Case ID: 140801554

3. The real estate, which is the subject of this litigation is:

4818 griscom street Philadelphia Pa 19124
_______________________________________________________________

_______________________________________________________________
______________________________________________________________.
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:

Plaintiff's Purchased said property from Defendant #1 Brenda L Davila on 8/11/2012 for
_______________________________________________________________
98,000.00 us dollars, Defendant never notifed plaintiff there was a foreclosure action pending
_______________________________________________________________
against her and the property, on 8/7/2013 Plaintiff's found out there was a foreclosure action
_______________________________________________________________
Advised wellsfargo that property was purchased from defendant #1 and that plaintiff's would
_______________________________________________________________
Like to settle this foreclosure dispute and pay property off in full wells fargo advised plaintif's
_______________________________________________________________
that they would not foreclose and send over a agreement to settle foreclosure but said it would
_______________________________________________________________
Take a couple weeks to get it together, they never sent agreement and countinued with the
_______________________________________________________________
foreclosure action without notice to Plaintiff's and then property was sold off at public auction
_______________________________________________________________
to law firm Zucker, Goldberg & Ackerman for 13,800.00
_______________________________________________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Case ID: 140801554

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:
4818 griscom street Philadelphia Pa 19124
________________________________________________________________________

________________________________________________________________________
________________________________________________________________________
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

8/12/2014
Date: _______________________

Case ID: 140801554

NAME OF FILING PARTY:

Terrance Rodriguez (Filing USA)
___________________________________
Name

7311 Oxford Ave

___________________________________
Address

Philadelphia, Pa 19111
___________________________________
City, State, Zip

8778237924 ext 201

___________________________________
Telephone

___________________________________

Jaeziel Vasquez
______________________________
Pa Housing And Credit Solutions
______________________________
Plaintiff

vs.
Wells Fargo Bank NA
______________________________
Zucker, Goldberg & Ackerman
______________________________
Defendant

:
:
:
:
:
:
:
:
:
:
:

PHILADELPHIA COUNTY
COURT OF COMMON PLEAS
TRIAL DIVISION - CIVIL

_________ TERM, _____________

Month

Year

No. ________________________

AFFIDAVIT OF PLAINTIFF
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF PHILADELPHIA

:
:
:

ss.

Jaeziel Vasquez
I, _____________________________
(Plaintiff), being duly sworn according to

law, depose and say that the facts stated herein are true and correct.

________________________________
Plaintiff

__________________________________
Plaintiff

Case ID: 140801554

VERIFICATION

Pa Housing And Credit Solutions & Jaeziel Vasquez

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

8/12/2014
Dated: _____________________

Case ID: 140801554

MOTION TO PROCEED IN FORMA PAUPERIS

PHILADELPHIA COURT OF COMMON PLEAS

CONTROL NUMBER:

PETITION/MOTION COVER SHEET

FOR COURT USE ONLY
ANSWER/RESPONSE DATE:

(RESPONDING PARTIES MUST INCLUDE THIS

NUMBER ON ALL FILINGS)

ASSIGNED TO JUDGE:

Do not send Judge courtesy copy of Petition/Motion/Answer/Response.

Status may be obtained online at http://courts.phila.gov

Term,

Month

Year

No.
Name of Filing Party:

vs.

INDICATE NATURE OF DOCUMENT FILED:

Petition (Attach Rule to Show Cause)
Motion
Answer to Petition
Response to Motion

(Check one)
(Check one)

Plaintiff
Movant

Defendant
Respondent

Has another petition/motion been decided in this case?

Yes

No

Yes
Is another petition/motion pending?
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 to which you are
responding):

I. CASE PROGRAM
Is this case in the (answer all questions):
A. COMMERCE 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/MAJOR JURY PROGRAM Year

Name of Judicial Team Leader:
Applicable Petition/Motion Deadline:
Has deadline been previously extended by the Court?
Yes
No
C . NON JURY PROGRAM
Date Listed:
D. ARBITRATION PROGRAM
Arbitration Date:
E. ARBITRATION APPEAL PROGRAM
Date Listed:
F. OTHER PROGRAM:
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.
(Attorney Signature/Unrepresented Party)

(Date)

(Print Name)

(Attorney 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 the parties so stipulate.
Case ID:
30-1061A (Rev. 7/05)

140801554

Instructions for completing

Petition to Proceed
In Forma Pauperis
1. All blanks and all questions MUST be filled in or answered.
Dollar amounts MUST be clearly stated where requested.
2. A copy of your latest Pennsylvania tax or federal tax return
should be attached.
3. Service of a copy of this petition MUST be made on the
opposing party or opposing partys attorney.
4. Please attach a self-addressed, stamped envelope for
yourself and an addressed, stamped envelope for each
opposing party or opposing partys attorney.
5. Petitioner is required to have the enclosed Affidavit notarized
by a licensed Notary Public.
6. Your petition may be dismissed or denied for 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.

Case ID: 140801554

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, 20_________
(month)

(year)

NO._________________________________

In Forma Pauperis Order

AND NOW, this ____________day of ________________________, 20_______ , it is
hereby ORDERED AND DECREED that:

1. Petitioner be permitted to proceed without paying the costs of this proceeding or

posting a bond.
2. Petitioner be permitted to obtain service of the papers filed without 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)

Case ID: 140801554

Court Term________________20____and 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.
5. Petitioner has a continuing obligation to inform the Court of any improvement in partys
financial circumstances that will enable the party to pay costs.
BY THE COURT:

________________________________________
J.

Page 2 of 11

Case ID: 140801554

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)

:
:
:
:
:
:
:
:
:
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:

___________________, 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 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

Case ID: 140801554

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.
4. I have the following average monthly expenses for the indicated items:
Housing: __________________

Insurance:

____________________

Utilities: __________________

Transportation: __________________

(Gas):

__________________

Medical:

____________________

(Oil):

__________________

Loans:

____________________

(Electric):__________________

Laundry:

____________________

(Phone): __________________

Child Care:

____________________

Food:

__________________

Child Support: ____________________

Clothing: __________________

5. I neither own nor have equity in any assets other than the following (state values in
dollars): ____________________________________________________________________
___________________________________________________________________________
6. I am unable to pay the costs of these proceedings or to obtain the amount of costs
from family or friends.

Page 4 of 11

Case ID: 140801554

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.
_______________________________________
Petitioner
(Print your name)
_______________________________________
Petitioner
(Sign your name)

Page 5 of 11

Case ID: 140801554

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, 20____

(Month)

(Year)

NO. _______________________________

Petitioners Affidavit
Pursuant to PA. R.C.P. 240
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF PHILADELPHIA

:
:
:

SS.

1. I, _________________________________________, am the (Plaintiff) (Defendant)

(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

Case ID: 140801554

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:
(a) Name: _____________________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
Social Security #_____________________________________________________________
(b) EMPLOYMENT
If you are presently employed, state:
Employer :

_______________________________________________________________

Address:

_______________________________________________________________
_______________________________________________________________

Salary/wages
Per Month: ______________________________________________________________
Type of Work: ______________________________________________________________
If you are presently unemployed, state:
Date of last Employment:

__________________________________________________

Salary/Wages
Per Month: ______________________________________________________________
Type of Work:______________________________________________________________
(c) OTHER INCOME WITHIN THE PAST TWELVE (12) MONTHS
(state as dollar amounts)
Business or Profession:_______________________________________________________
Other Self-employment: _____________________________________________________

Page 7 of 11

Case ID: 140801554

Interest:___________________________________________________________________
Dividends:_________________________________________________________________
Pension and Annuities:________________________________________________________
Social Security Benefits:_______________________________________________________
Support Payments:___________________________________________________________
Disability Payments:_________________________________________________________
Unemployment Compensation &
Supplemental Benefits: _____________________________________________________
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: _________________________________________________________________
Salary/Wages
Per Month: ______________________________________________________________
Type of Work:______________________________________________________________
Contributions
From Children: _____________________________________________________________
Contributions
From Parents: ______________________________________________________________
Other Contributions:__________________________________________________________

(e) PROPERTY OWNED (state as dollar amounts)

Cash:______________________________________________________________________

Page 8 of 11

Case ID: 140801554

Checking Account:___________________________________________________________
Savings Account:____________________________________________________________
Certificates of Deposit:________________________________________________________
Real Estate
(Including Home): ___________________________________________________________
Motor Vehicle: Make _______________________________ Year __________________
Cost $_________________________________

Amount Owed Z

Stocks & Bonds: ____________________________________________________________

Other: _____________________________________________________________________
_____________________________________________________________________

(f) DEBTS AND OBLIGATIONS (state as dollar amounts)

Mortgage: __________________________________________________________________
Rent:

__________________________________________________________________

Loans:

__________________________________________________________________

Other:

__________________________________________________________________

(g) PERSONS DEPENDENT UPON YOU FOR SUPPORT

(Wife) (Husband) Name: ______________________________________________________
Children, if any: _________________________________Age _______________________
_________________________________Age _______________________
_________________________________Age _______________________
_________________________________Age _______________________
Other Persons:
Name:_________________________________________________________________

Page 9 of 11

Case ID: 140801554

Relationship: __________________________________________________________

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 true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn
falsification to authorities.

Dated: ____________________

__________________________________________
Petitioner
(Print your name)

__________________________________________
Petitioner
(Sign your name)

Sworn to and subscribed before me this

______ day of ______________,20______.
__________________________________
Notary Public

Page 10 of 11

Case ID: 140801554

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

(Print Name)

(Sign your name)

Dated: ________________________

Page 11 of 11

Case ID: 140801554