Affidavit In Support Of Motion To Proceed In Forma Pauperis

<document>APPENDIX CIN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIOCASE NO:In the matter of:Indigency of::::::::::Affidavit in Support of Request to ProceedIn Forma PauperisINSTRUCTIONS:In order for the Court to properly consider yourapplication, 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.Are you employed? Yes NoI.If you answered "yes":A.(1)What is the name and address of your employer? How much do you earn per month? (2)B.If you answered "no":(1)Have you ever been employed? YesNoIf "yes", what was the last year and month you wereemployed? 2001 © American LegalNet, Inc.How much did you earn per month?What is your marital status?Single Married Widowed DivorcedII.If you answered "Married":A.Is your spouse employed?YesNo(1)If "yes", how much does your spouse earn each month? III.Do you have any dependents?YesNoA.If you answered "yes", list each dependent's name, age and their relationship to you:NameAgeRelationshipWithin 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 payments, disability payments?IV.Yes NoIf you answered "yes", describe each source of income andA.the total amount you received from that sourceover the twelve-month period:SourceAmountV.Do you or your spouse have any cash on hand or money in a savings, checking or other account? YesNo2001 © American LegalNet, Inc.If you answered "yes", state the combined total amount: $A.Do you or your spouse own any real estate, stocks, bonds, notes, automobiles or any other valuable property? YesVI.NoIf you answered "yes", describe each piece of property and state its value:A.ValuePropertyVII.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.CreditorAmount OwedVIII.State your address and a phone number where the court canreach you:(Signature of Plaintiff)STATE OF OHIO))ss:BUTLER COUNTY)Sworn to and signed before me this day of , 19.Notary Public2001 © American LegalNet, Inc.CERTIFICATE OF ATTORNEYI 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)2001 © American LegalNet, Inc.</document>