IN RE: ADMINISTRATIVE ORDER 1992-10 -- COUNSELING FEES FOR TERMINATION AND RELINQUISHMENT OF PARENTAL RIGHTS CASES
ORDER OF COURT
AND NOW, this 10th day of July, 1992, IT IS HEREBY ORDERED, in accord with Act 1992 34, that the County of Northampton establish a segregated fund into which shall be deposited the filing fee accompanying a report of intention to adopt. Disburse-ments from said segregated fund shall only be made upon court order to pay for counseling for individuals unable to pay for such counseling. Any individual who seeks counseling relating to termination or relinquishment of his or her parental rights and who claims to be unable to pay for such counseling shall file a petition with the court requesting payment for the counseling from said counseling fund. Attached to the petition shall be an affidavit in the form attached hereto.
BY THE COURT,
Robert A. Freedberg, P.J.
AFFIDAVIT
1. I am the parent of the minor(s) who (is)(are) the subject(s) of the termination/relinquishment proceeding captioned above.
2. Because of my financial condition I am unable to pay for counseling for myself regarding the termination/relinquishment of my child(ren).
3. I represent that the information below relating to my ability to pay is true and correct:
(a) Name: ______________________________________________________
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: ______________________________________________
(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______________________________________
Public assistance __________________________________________
Other: _____________________________________________________
_____________________________________________________
(d) Other contributions to household support
(Wife)(Husband) Name: ______________________________________
If you (wife)(husband) is employed, state
Employer: _____________________________________________
Salary or wages per month: ____________________________
Type of work: _________________________________________
Contributions from children: __________________________
Contributions from parents: ___________________________
Other contributions: __________________________________
(e) Property owned
Cash: ______________________________________________________
Checking account: __________________________________________
Savings account: ___________________________________________
Certificates of deposit: ___________________________________
Real estate (including home): ______________________________
Motor vehicle: Make _________________, Year ____________,
Cost __________, Amount Owed _____________
Stocks; bonds: _____________________________________________
Other: _____________________________________________________
_____________________________________________________
(f) Debts and obligations
Mortgage: __________________________________________________
Rent: ______________________________________________________
Loans: _____________________________________________________
Other: _____________________________________________________
_____________________________________________________
(g) Persons dependent upon you for support
(Wife)(Husband) Name: ______________________________________
Children, if any:
Name ______________________________________ Age ____________
______________________________________ ____________
______________________________________ ____________
Other persons:
Name: ______________________________________________________
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.
Date:____________________
Petitioner: __________________________________