Free Application to Proceed Without Prepayment of Fees and Affidavit - Ohio

(Form IN FORMA PAUPERIS-Rev. 4/20/05, S.D. of Ohio)

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO WESTERN DIVISION

Plaintiff(s)

Case No.

vs.

Defendants(s)

APPLICATION/ MOTION TO PROCEED WITHOUT PREPAYMENT OF FEES (IN FORMA PAUPERIS) AND AFFIDAVIT IN SUPPORT THEREOF

Instructions: In order for the Court to properly consider your application, you must answer each question below and provide the information requested. No application will be considered until it is fully completed.

I. Are you employed? Yes____ No____ A. If you answered "Yes": (1) What is the name and address of your employer ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (2) How much do you earn per month? ______________________________________________________________________________

B. If you answered "No" (1) Have you ever been employed? Yes____ No_____ If yes, what was the last year and month you were employed? ______________________________________________________________________ How much did you earn a month?____________________________________________________

II. What is your marital status? Single_____ Married______ Widowed_______ Divorced______ A. If you answered "Married": (1) Is your spouse employed? Yes_____ No_____ If yes, how much does your spouse earn each month? $_____________________________________________________________________________

III. Do you have any dependents? Yes____ No____ If you answered "Yes" list each dependent's name (minor children should be identified only by their initials), relationship to you, and the amount you contribute to their support: Name Relationship Amount ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

IV. Within the past twelve (12) months, have you received any income from a business, profession or other form of self-employment, or in the form of rent payments, retirement benefits, annuity payments, interest or dividends, or any other source? Yes____ No_____ A. If you answered "Yes," describe each source of income and the total amount you received from that source over the twelve-month period: Source Amount Source Amount ___________________________$__________ ___________________________$__________ ___________________________$__________ _____________________$________ _____________________$________ _____________________$________

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V. Do you have any cash on hand or money in a savings, checking, or other account? Yes_____ No____ A. If you answered "Yes", state the combined total amount: $___________________.

VI. Do you own any real estate, stocks, bonds, notes, automobiles, or any other valuable property? Yes____ No____ A. If you answered "Yes", describe each piece of property and state it's value: Property Value Property Value __________________________$________ _________________________$________ __________________________$________ _________________________$________ __________________________$________ _________________________$________ __________________________$________ _________________________$________

VII. List all your creditors, including banks, loan companies, charge accounts, personal loans, rent, utilities, child support, etc., and the amount you pay each month on each bill/obligation: Amount Owed Creditor Amount Owed Creditor ___________________________$_____________ ___________________________$_____________ ___________________________$_____________ ___________________________$_____________ _____________________$_____________ _____________________$_____________ _____________________$_____________ _____________________$_____________

VIII. State your address and telephone number where the Court can reach you. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

I declare under penalty of perjury that the above information is true and correct.

_______________________ Date

_________________________________________ Signature of Applicant

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