IN THE COURT OF CLAIMS OF OHIO Plaintiff/Claimant Case No. v. APPLICATION TO WAIVE FILING FEE Defendant 1. I am financially unable to pay the filing fee in this action and that my financial inability to make such deposit is due to: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ I further state that in the last 12 months, I have worked for the following (names and addresses required): (If unemployed at this time, state "UNEMPLOYED."). ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ I further state that I have received public assistance in the previous twelve (12) months from: (If none, state "NONE."). ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ I further state that I have bank balances (savings accounts, CD's, checking accounts and/or IRA and stocks or bonds) as set forth below: (State the entity, type of account maintained and approximate balance.). ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 2. 3. 4. American LegalNet, Inc. www.FormsWorkFlow.com Case No. _________________ -2- APPLICATION TO WAIVE FILING FEE 5. The number and ages of dependents residing with me and for whom I am responsible: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ I own the following real estate (even if there is a lien): _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ I own the following motor vehicles (even if there is a lien): _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ I further understand that this Application only waives filing fees as required by the Court in this matter, and that, upon the conclusion of this matter, I may be responsible for paying any court costs. 6. 7. 8. NOTE: USE REVERSE SIDE OF THESE PAGES, IF ADDITIONAL SPACE IS REQUIRED. ___________________ Date ___________________________________________ Signature of Plaintiff/Claimant Address: ______________________________ ______________________________ Telephone: ______________________________ Email Adress: ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com