APPENDIX B IN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIO : : : : : : CASE NO: APPLICATION TO PROCEED IN FORMA PAUPERIS, SUPPORTING DOCUMENTATION AND ORDER : : : : I declare that I am the (check appropriate status) ______ petitioner/plaintiff ______ movant ______ respondent/defendant ______ ____________(other) in the above-entitled proceeding; that, in support of my request to proceed without being required to prepay fees and costs. I state that because of my poverty, I am unable to pay the costs of said proceeding that I believe I am entitled to relief. In further support of this application, I submit the attached affidavit. I declare under penalty of perjury that the foregoing is true and correct. Executed On:_________________ (date) ______________________________ (signature of applicant) Approved: ____________________________ Judge, Court of Common Pleas 2001 © American LegalNet, Inc.