APPENDIX B (L.R. 2.04, fka 1.09) IN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIO In the matter of Indigency of: : CASE NO: : AFFIDAVIT IN SUPPORT OF _____________________________ (Applicant Name) 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. Yes______No______ 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 per month? _____________________ II. What is your marital status? Single______Married______ Widowed______Divorced______ American LegalNet, Inc. www.FormsWorkflow.com A. (1) III. If you answered “Married”: Is your spouse employed? Yes______ No______ If “Yes”, how much does your spouse earn each month? _____________________________________________________ Do you have any dependents? A. Yes______No______ 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 payments, disability payments? 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: Amount Source ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ V. Do you or your spouse have any cash on hand or money in a savings, checking or other account? Yes______No______ A. VI. If you answered “Yes,” state the combined total amount: $________________________ Do you or your spouse own any real estate, stocks, bonds, notes, automobiles or any other valuable property? Yes______ No______ American LegalNet, Inc. www.FormsWorkflow.com A. If you answered “Yes,” describe each piece of property and state its 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 ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 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 __________, 20_____. _____________________________ 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) American LegalNet, Inc. www.FormsWorkflow.com