Warren-Forest Court of Common Pleas Thirty Seventh Judicial District
of the Commonwealth of Pennsylvania

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 will assign counsel to represent indigents in civil actions where deprivation of substantial rights may occur, such as dependency actions and actions to terminate parental rights. 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 37TH 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

			_____________________________