PHILADELPHIA MUNICIPAL COURT First Filing Unit 1339 Chestnut

PHILADELPHIA MUNICIPAL

COURT First Filing Unit

1339 Chestnut Street, Room 1000

PHILADELPHIA, PA 19107

215-686-7988/2901

T. Francis Shields

President Judge

Instruction Sheet for the Statement of Claim Form

The Statement of Claim form must be typed. When completing the form, note the following:

You must have the full names and street addresses for all parties. No initials such as Mrs., Mr., etc., are

acceptable.

The body of the complaint should clearly and concisely state the reason you are bringing suit. Include the dates

on which transactions occurred.

Complete the affidavit of non-military page that follows the Statement of Claim form for each individual defendant.

This is not required if the defendant is a business or organization.

Include all exhibits relevant to your claim. Your exhibits will be uploaded to the docket. A copy will be sent to the

defendant. Exhibits may include bills, receipts, contracts, invoices, and any other documentation that helps prove

your case on the day of the hearing. If your claim involves persona injury or property damage and is over

$2,000.00, fill out the enclosed Claim Fact Sheet.

To determine the fee associated with your claim refer to the fee schedule or contact our office. We accept Money

Orders, Business Checks, and Attorney Checks. No personal checks will be accepted. Checks should be made

payable to Office of Judicial Records.

All complaints are filed by the First Filing Unit, 1339 Chestnut Street, Philadelphia, PA 19107. Mail your complaint

to this address. Include a self-address stamped envelope with your filing, to receive your filed complaint,

pertinent forms and hearing information.

For Corporations to file, only an executive officer may sign the form. The executive officer that files the complaint

is expected to appear in Court, unless they complete an Appointment of Authorized Representative Form. When

a corporation files a complaint, they must include documentation to certify the position of the executive officer.

We can accept minutes of a meeting, articles of incorporation, or a signed tax return. Only the President, Vice

President, Secretary, or Treasurer has the authority to sign and appear for the corporation unless an authorized

representative form is completed.

. If the party being sued is not an individual, you should make sure that you have the correct name of the

corporation, partnership, limited liability entity. For assistance with locating Pennsylvania entities, you may wish

to contact Pennsylvania’s Corporation Bureau at https://www.corporations.pa.gov at 717-787-1057. For

assistance in locating an entity that does business in Philadelphia, you may wish to check to see if the entity has

a Philadelphia Commercial Activity license by contacting the Department of Licenses and Inspections License

Issuance Unit. It is located in the Concourse Level of the Municipal Services Building, 1401 JFK Boulevard and

may reached by calling 311.

Before mailing any complaint to our office it’s recommended that you contact us and verify that all your

documents and fees are in order.

COMMONWEALTH OF PENNSYLVANIA

The Philadelphia Municipal Court

1339 Chestnut Street, Philadelphia, PA 19107

T. Francis Shields, President Judge

Typed By:

Approved:

Code:

Court

Costs:

STATEMENT OF CLAIM

Plaintiff(s)

Defendant(s)

[ ] Motor Vehicle case—Defendant License

Information:

Date of Accident:

License Plate No.

Defendant—Operator No.

Owner—Operator No.

TO THE DEFENDANT: The above named plaintiff(s) ask judgment in this Court against you for $

plus court costs upon the following claim:

Principal Amount

Interest at %

From:

Attorney’s Fee

Other

Total:

COUNSEL FOR PLAINTIFF:

PHONE No:

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF PHILADELPHIA SS:

DEPOSE AND SAY THAT THE FACTS

SET FORTH ARE TRUE AND CORRECT

AND ACKNOWLEDGE THAT I AM

SUBJECT TO THE PENALTIES OF 18

P.S. 4904 RELATING THE UNSWORN

FALSIFICATION TO AUTHORITIES.

SIGNATURE PLAINTIFF/ATTORNEY

SUMMONS TO THE DEFENDANT:

YOU ARE HEREBY ORDERED TO

APPEAR AT A HEARING

SCHEDULED AS FOLLOWS:

CITATION: AL DEMANDADO POR LA

PRESENTE, USTED ESTA DIRIJIDO A

PRESENTARSE A LA SIGUIENTE

LOCATION (SITO)

COURTROOM , SIXTH FLOOR

1339 CHESTNUT STREET

DATE: (FECHA)

TIME: (HORA)

NOTICE TO THE DEFENDANT: YOU HAVE BEEN

SUED IN COURT.PLEASE SEE ATTACHED NOTICE.

NOTA IMPORTANTE PARA EL ACUSADO: USTED HA SIDO

DEMANDO EN CORTE. POR FAVOR MIRA PAPELE

ESCRITA.

SIGNATURE—PLAINTIFF/ATTORNEY

I, depose and say that the facts set forth in

this complaint are true and correct and acknowledge that i am subject to the penalties of 18

P.S. 4904 relating to unsworn falsification to authorities.

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF PHILADELPHIA :SS

The Philadelphia Municipal Court

AFFIDAVIT OF NON-MILITARY SERVICE

State of Pennsylvania:

County of Philadelphia:

: ss.

, being duly sworn according to law, deposes and says that

he/she (is) (represents) the Plaintiff(s) in the above entitled case; that he/she is authorized to make

this affidavit on behalf of the plaintiff(s); and that the above-named Defendant(s) is (are)

years of age; the address of the defendant(s) is:

Occupation of defendant(s) is

and Defendant is not in the Military Service of the United States, nor any State or Territory thereof or

its allies as defined in the Soldiers’ and the Sailors’ Civil Relief Act of 1940 and the amendments

thereto.

ACKNOWLEDGMENT

DOCUMENT

REVIEW

Read the following acknowledgments to ensure that you are satisfied with the filing, the wording in the Landlord-Tenant Complaint

form and that you agree that all personal information has been removed from each and every documentused in your filing as

our docket is available for public viewing.

You agree that you have read the entire filing and agree with the wording, terminology and

content.

You agree that all of the names, addresses (including suite, apartment numbers andfloors}

and any other information in the caption block are correct.

You agree that it is your responsibility to remove all personal information that is shown on any

form used in the filing. This includes information pertaining to you, any party named in the filing

and any other individual who has information included in the documents submitted as

evidence. This information includes, but is not limited to,

phone numbers, account numbers, social security numbers, routing numbers, bank accounts and tax information.

You have submitted, if available, your email address and cell phone number in case you

need to be contacted by the court regarding the filing.

By signing this form, you agree that you have read the document in full, have been giventhe opportunity to revise your

filing and/or to ask any questions regarding the filing process.

Filer: Date:

Court Representative:

PHILADELPHIA MUNICIPAL COURT

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA

General Affidavit for Municipal Court Rule #109

I, , depose and say that the facts set forth in this affidavit are

true and correctand knowledge that I am subject to penalties of 18 P.S. 4904 relating to Unsworn Falsification to Authorities.

Signature

I affirm that the name of the Defendant is the

only oneknown. I have made a reasonable investigation and this is the only known name.

An invoice or statement of account is not available for the reason that

The contract or writing upon which this claim is based is not available because

and a statement of the pertinent portions or substance of the writing is attached.

This claim involved repairs and I do not have an estimate to repair or a repair bill and I have

stated the reasons for this in the complaint.

A copy of the lease is not available for the reason that

The license is not attached.

A copy of the notice to quit is not available for the reason that

The particulars of the notice are as follows:

Date the notice was sent to Tenant

Date Tenant was given to move by was

How as the notice served on the Tenant

Reason given to the Tenant in the notice (what was the breach of the lease, etc.)

The Municipal Court complies with the Americans with Disabilities Act, which requires that all Court services and facilities be accessible to persons

with disabilities on an equal basis to those without disabilities. If you have a disability and require reasonable accommodations to file a claim,

participate in Municipal Court proceeding, or use any service provided by the Court, please call 215-686-7986. Requests for reasonable

accommodations must be made atleast three business days before any hearing, or within three business days after service (delivery) of the Notice of

Hearing, whichever is later.

49-08/23/01

NO.

PLAINTIFF(S)

DEFENDANT(S)

APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM (RULES 102 AND 131)

The following section is to be completed by the individual on behalf of the party that is appointing an Authorized Representative:

I, , on behalf of Name of Appointing Individu

a party in the above-captioned matter, do hereby certify that the party is one of the following: (check one)

[ ] an individual or sole proprietor; [ ] a corporation; [ ] a general partnership; [ ] a limited partnership; [ ] a limited liability

company; [ ] a professional association; or [ ] a business trust.

I further certify that I have authority to execute this form on behalf of the party and that I am: (check one)

[ ] the individual or sole proprietor that is the party; [ ] an officer of the corporation that is the party; [ ] a partner of the

general partnership that is the party; [ ] a general partner of the limited partnership that is the party; [ ] a manager of

the limited liability company that is the party; [ ] an officer of the board of governors of the professional association that

is the party; or [ ] a trustee of the business trust that is theparty.

I hereby authorize to act as an Authorized Representative of the party

named above and certify that the Authorized Representative has personal knowledge of the facts and circumstances of the

above- captioned matter and is actingas an agent of the party. The nature and extent of the authorized representative’s

authority is limited to the following: (check as many as are applicable)

[ ] filing a statement of claim; [ ] filing a landlord tenant complaint; [ ] negotiating an amicable resolution of the matter;[

]participating at trial by testifying, submitting documents into evidence, asking questions of witnesses and making

argument, and [ ] filing or responding to a petition to open a default judgment.

I hereby verify that the facts set forth above are true and correct to the best of my knowledge, information

and belief. I further acknowledge that this verification is made subject to the penalties for making an unsworn

falsification to authorities in violationof 18 Pa. C.S. § 4904.

Printed Name: Signature of Appointing Individual

Date:

The following section is to be completed by the Authorized Representative:

I, , do hereby verify, to the best of my knowledge, information and belief, that I

have personal knowledge of the facts and circumstances of the above-captioned matter. I further acknowledge that this

verification is made subject to the penalties for making an unsworn falsification to authorities in violation of 18 Pa. C.S. §

4904. Printed Name: Signature of Authorized Representative:

Date:

PHILADELPHIA MUNICIPAL COURT

1339 CHESTNUT STREET, 10

FLOOR

PHILADELPHIA, PA 19107

There are 3 sections in this form.

Section 1: The party asking for an Authorized Representative will fill out Section 1. This section verifies that they are

allowed to have an Authorized Representative.

Section 2: The party asking for an Authorized Representative will also fill out Section 2. This section verifies what the

Authorized Representative can do.

Section 3: The person appointed as an Authorized Representative will fill out Section 3. This section verifies the

Authorized Representative's qualifications in this case. It verifies they have personal knowledge of the facts and

circumstances of the case.

APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM

(RULES 102 AND 131)

In the Philadelphia Municipal Court

Instructions for Appointing a Representative in a Philadelphia Municipal Court Civil Case

NO.

PLAINTIFF(S)

DEFENDANT(S)

Philadelphia Municipal Court Rule of Civil Procedure 131 authorizes a party in a civil case to appoint a representative who

is authorized to act on behalf of a party.

An Authorized Representative is a person who acts on behalf of a party (another person) in a case. The Authorized

Representative can ONLY act for a party that has completed an Appointment of Authorized Representative

Form.

Parties need to verify that they are allowed to appoint an Authorized Representative. Filling out this form will provide the

required information to verify they can.

To appoint an Authorized Representative, a party must:

•

Believe and verify that the Authorized Representative knows enough about the facts of the case,

•

Fill out the Appointment of Authorized Representative Form,

•

Have the Authorized Representative fill out Section 3 of the Appointment of Authorized Representative Form, and

•

Submit the form to the court BEFORE the court proceeding starts.

A party is always allowed to limit or cancel an Authorized Representative’s right to act on behalf of the party. The party

would need to file a document with the court to do so.

In the Philadelphia Municipal Court

Section 1

APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM

(RULES 102 AND 131)

Please enter the name of the party appointing an Authorized Representative in the text box below.

Name of the party listed in the case name (could be your own name)

By signing this form, I verify that the party named above is one of the following: (check one)

a person;

the sole proprietor (owner of a business);

a corporation;

a general partnership;

a limited partnership;

a limited liability company;

a professional association; or

a business trust.

By signing this form, I verify that I am one of the following: (check one)

the person named in the case;

the sole proprietor (owner) named in the case;

an officer of the corporation named in the case;

a partner of the general partnership named in the case;

a general partner of the limited partnership named in the case;

a manager of the limited liability company named in the case;

an officer of the board of governors of the professional association named in the case; or

a trustee of the business trust named in the case.

The person appointing an Authorized Representative in this case must fill out this Section.

This Section verifies that the party named in the case can have an Authorized Representative.

The person appointing an Authorized Representative must fill out this Section.

This Section requires you to select the actions you want the Authorized Representative to do. Below is a list of

all the actions an Authorized Representative can do.

NOTE: You may limit or end the Authorized Representative’s authority at any point by filing a document with the

court limiting or terminating the Appointment.

By signing below, you are verifying that all the information in Sections 1 AND 2 of this form are true and correct to the

best of your knowledge, information, and belief.

The Authorized Representative must complete this section:

By signing below, you are verifying that all the information in Section 3 of this form is true and correct to the best of your

knowledge, information, and belief.

AUTHORIZATION

I now authorize

(Name of the person being appointed as an

Authorized Representative)

to act as an Authorized Representative of the party named above. I also verify that the Authorized Representative has

personal knowledge of the facts and circumstances of the matter. I certify that the Authorized Representative will act in the

interest of the named party.

Section 2

The Authorized Representative may do any of the following on my behalf: (check as many as apply)

file a claim;

file a landlord-tenant complaint;

negotiate an agreement to the matter;

participate at trial by testifying, submitting documents into evidence, asking witnesses questions, and making

arguments; and

file or respond to a petition of default judgment (a judgment entered against a party when that party fails to appear in

court).

Lying on this court form is a crime that is punishable by the penalties outlined in 18 Pa. C.S. § 4904

Printed Name:

Signature of Appointing Individual: Date:

Section 3

Your Name:

I verify, to the best of my knowledge, information, and belief, that I have personal knowledge of the facts and

circumstances of the matter above.

Lying on this court form is a crime that is punishable by the penalties outlined in 18 Pa. C.S. § 4904

Printed Name:

Signature of Authorized Representative: Date:

CERTIFICATE OF COMPLIANCE

I certify that this filing complies with the provisions of the Public Access Policy of the Unified Judicial

System of Pennsylvania: Case Records of the Appellate and Trial Courts that require filing confidential

information and documents differently than non-confidential information and documents.

Submitted by:

Signature:

Name:

Attorney No. (if applicable):

MUNICIPAL COURT NOW OFFERS EMAIL NOTIFICATION!

By choosing to provide your email address, you will forgo most regular mail notification and instead, receive instant

electronic notification regarding significant events which may occur on your case. Your email address is for internal use

only and will be kept confidential. It will not appear on your docket or any paperwork associated with your case. Please

fill out the information below and return it to the clerk.

First Judicial District of Pennsylvania

Philadelphia Municipal Court

1339 Chestnut Street, Philadelphia, Pa 19107

Joffie C. Pittman T. Francis Shields Administrative Judge

President Judge

E-MAIL AFFIDAVIT

I, ___________________________, being the Plaintiff/Defendant in claim number ______________________,

(Print Name)

hereby give my permission to receive notice of future docket updates via e-mail address:

________________________________________________________________________________________.

I understand by signing this affidavit I will no longer receive such updates via regular mail. I also understand that

signing this affidavit in no way waives Pennsylvania law and/or Pennsylvania/Philadelphia Court procedures

regarding service for legal filings on this claim.

__________________________________________ ____________________

PLAINTIFF/DEFENDANT SIGNATURE DATE

I do not want to provide an email address at this time.

_________________________________ ____________________

PLAINTIFF/DEFENDANT SIGNATURE DATE

NO.

PLAINTIFF(S)

DEFENDANT(S)

CLAIM FACT SHEET – BODILY INJURY / PROPERTY DAMAGE

To The Claimant: All questions must be answered. Information not supplied may not be introduced at the time of the

trial.

NOTE: The contents of this fact sheet and attachments may not be admissible at trial, if prohibited by the Rules of Evidence.

1. List the names and addresses of all witnesses to this accident and/or event.

2. List and attach copies of all medical bills, narrative reports, discharge summaries, property damage andloss of earning documents and claims.

3. List and attach copies of all estimates, obtained from any source, for damage to property.

4. If bodily injury is being claimed, list the date, place and any other parties involved in any earlier orlater bodily injuries and the same part(s) of the

body that were injured in this claim.

5. Regarding your insurance, if known, state:

a. Name of Company:

b. Address:

c. Policy Number:

d. Claim Number:

e. Claim Adjuster Handling File:

6. List and describe photos and/or exhibits that you may introduce at the time of the trial.

Understanding that false statements herein are subject to the penalties of 18 PA. C. S. Section 4904 (relating to unsworn falsification to

authorities), I certify that the above answers are true and correct to the best of my knowledge, information, and belief.

I hereby authorize the other parties to this action or their representative(s) to obtain my medical reports, employment attendance and

compensation records, pertaining to this specific claim, to the extent not privileged.

Claimant

THE MUNICIPAL COURT COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT, WHICH REQUIRES THAT ALL COURT SERVICES AND FACILITIES BE ACCESSIBLE TO

PERSONSWITH DISABILITIES ON AN EQUAL BASIS TO THOSE WITHOUT DISABILITIES. IF YOU HAVE A DISABILITY, AND REQUIRE REASONABLE ACCOMMODATIONS TO

FILE A CLAIM, PARTICIPATE IN A MUNICIPAL COURT PROCEEDING, OR USE ANY SERVICE PROVIDED BY THE COURT, PLEASE CALL 215-686-7986. REQUESTS FOR

REASONABLE ACCOMMODATIONS MUST BE MADE AT LEAST THREE BUSINESS DAYS BEFORE ANY HEARING, OR WITHIN THREE BUSINESS DAYS AFTER SERVICE

(DELIVERY) OF THE NOTICE OF THE HEARING WHICHEVER IS LATER.

PHILADELPHIA MUNICIPAL COURT

1339 CHESTNUT STREET, 10

FLOOR

PHILADELPHIA, PA 19107