Free Document - Ohio

APPENDIX C

IN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIO

In the matter of Indigency of:

: : : : : : : : :

CASE NO:

:

Affidavit in Support of Request to Proceed In Forma Pauperis

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. If necessary, attach additional pages. I. Are you employed? A. (1) Yes______ No______

If you answered "yes": What is the name and address of your employer? _______________________________________________________ _______________________________________________________ How much do you earn per month? _______________________________________________________ If you answered "no": Have you ever been employed? Yes______ No______ If "yes", what was the last year and month you were employed? _____________________________________________

(2)

B. (1)

How much did you earn per month?________________________

II.

What is your marital status? Single______ Widowed______ Divorced______ A. (1) If you answered "Married":

Married______

Is your spouse employed? Yes______ No______ If "yes", how much does your spouse earn each month? _____________________________________________________ Yes______ No______

III. Do you have any dependents? A.

If you answered "yes", list each dependent's name, age and their relationship to you: Name Age Relationship _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

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, interest dividends, retirement benefits annuity payments or any other source including Workers Compensation, Social Security Yes______ No______ payments, disability payments? 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 _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

V.

Do you or your spouse 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 or your spouse own any real estate, stocks, bonds, notes, automobiles or any other valuable property? No______ Yes______ A. If you answered "yes", describe each piece of property and state its value: Value Property _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

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. Creditor Amount Owed ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ VIII. State your address and a phone number where the court can reach you: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

______________________________ (Signature of Plaintiff) STATE OF OHIO) ) ss: BUTLER COUNTY) Sworn to and signed before me this _____ day of ____________, 19_____. ______________________________ Notary Public

CERTIFICATE OF ATTORNEY I have examined the answers given by my client in this questionnaire and to the best of my knowledge and belief, the answers are true and accurate.

______________________________ (Attorney's Signature)