FORM 19.17 Statement of Fees and Costs

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

STATEMENT OF FEES AND COSTS

_________ _________, Esquire

Attorney's Name

ATTORNEY'S FEE:

Itemization of Costs:

Total Fees and Costs:

(Signature) __________________

Esquire

(Signature) __________________

Petitioner

(Signature) __________________

Petitioner

(Verification)