For. Cnty. Pa. 240

As amended through January 1, 2018

Rule 240 - In Forma Pauperis - Appointment of Counsel

The Court desires that legal services in civil actions shall be provided to indigents and qualified persons. Upon petition filed with the Court pursuant to motions practice, the Court may assign counsel to represent indigents in civil actions where deprivation of substantial rights may occur. The petition for the assignment of counsel in a civil action shall be in the form set forth on Exhibit L240 of these rules. A supply of these forms shall be maintained by the Prothonotary and the Domestic Relations Section.

IN THE COURT of COMMON PLEAS

OF THE 37T H JUDICIAL DISTRICT

OF PENNSYLVANIA

_______________ COUNTY BRANCH

PETITION FOR THE APPOINTMENT of COUNSEL IN A CIVIL ACTION

TO THE HONORABLE ____________________ , THE JUDGE of SAID COURT:

The petitioner respectfully represents and petitions the court as follows:

1. Petitioner is _______________________ who resides at _______________________________ and is the

(plaintiff) (defendant) in the above entitled action.

2. Petitioner's social security number is __________ and his/her income and expense information as set forth below is complete and true.

3. That this is an action for ______________

4. That this is a civil action which may lead to the deprivation of substantial rights of the petitioner and thus raises due process and equal protection questions where by the petitioner is entitled to the assignment of counsel.

5. That the petitioner is, for financial reasons, unable to obtain counsel to represent him/her in this action as the petitioner does not have sufficient income or assets to hire counsel nor does petitioner have the ability to borrow money or obtain gifts from relatives, friends, or otherwise in order to hire counsel. Petitioner has made the following efforts to obtain counsel: _______________________________________________________________

6. I represent that the information below relating to my ability to pay counsel fees is true and correct:

(a) Employment

(i) I am presently employed and state as follows:

Employer ____________________

Address ______________________

____________________________

Salary or wages per month ______

Type of work __________________

(ii) I am presently unemployed and state as follows:

Date of last employment _________

Salary or wages per month _______

Type of work _________________

(b) Other income within the past twelve months Business or profession __________

Other self-employment __________

Interest __________________________

Dividends ________________________

Pension and annuities ___________

Social security benefits __________

Support payments received _______

Disability payments ____________

Unemployment compensation and

supplemental benefits ___________

Worker's compensation _________

Public Assistance ______________

Other ___________________________

(c) Other contributions to the support of my household (wife) (husband) (other adult living with me) _______________________

( ) My (wife) (husband) (or other adult) is employed, and I state:

Employer _______________________

Salary or wages per month __________

Type of work ____________________

Contributions from children _________

Contributions from parents __________

Other contributions ________________

( ) My wife, husband, or other adult is not employed.

(d) Property owned

Cash ____________________________

Checking account __________________

Savings account ___________________

Certificates of deposit ______________

Real estate (including home): ________

Motor vehicle: Make___ Year _______

Cost ________ Amt.owed _______

Stocks; bonds ____________________

Other ___________________________

(e) Debts and obligations:

Mortgage ________________________

Rent ____________________________

Loans ___________________________

Other ___________________________

________________________________

(f) Persons dependent upon me for support

(Wife)

(Husband)

Name ________________________

Children, if any

Name Age

____________________ _____

____________________ _____

____________________ _____

____________________ _____

Other persons:

Name ________________________

Relationship __________________

7. Petitioner (is) (is not) receiving Public Assistance.

8. I agree that I have a continuing obligation to inform the Court and my court appointed counsel of any improvement in my financial circumstances which then may enable me to pay attorney's fees.

WHEREFORE, petitioner respectfully requests that this court appoint and assign counsel to represent him/her in this action. ___________________________________

(Print Name)

VERIFICATION

I, ____________________________ , verify that the statements made in this petition are true and correct to the best of my knowledge, information and belief. I understand that false statements made herein are subject to the penalties of 18 Pa. C.S.A. 4904 relating to unsworn falsification to authorities.

________________________________

(Sign Name)

ORDER

AND NOW, this _______ day of ______________ , _____ upon consideration of the within petition the Court believing, based upon the representation and sworn statements of the petitioner, that the petitioner is indigent; and the Court further believing that this action affects "substantial rights" of the petitioner raising due process and equal protection questions, the court concludes that the petitioner has a right to the assignment of counsel to represent him/her in this action.

Accordingly, _______________________ , Esq., is hereby appointed to represent the petitioner in this action until the petitioner in financially able to obtain counsel to represent him/her in this matter. In the latter event, counsel appointed to represent the petitioner shall continue to represent the petitioner either pursuant to an agreement between counsel and the petitioner regarding the payment of fees and costs or, in lieu thereof, counsel or the petitioner may file a motion or petition with this Court to determine the petitioner's ability to pay counsel fees and the terms and conditions thereof.

BY THE COURT

_____________________

For. Cnty. Pa. 240

Amended effective 1/14/2014 and 1/24/2014.