PURSUANT TO LOC.R. 9.02(B) OF THE FRANKLIN COUNTY COURT OF COMMON PLEAS, GENERAL DIVISION—If a party initiating a civil action believes that he/she is unable to pay cost, an affidavit of indigency must be filed and the following financial disclosure made: FINANCIAL DISCLOSURE 1. Employment and salary for the past 12 months: Employers name(s) and address(es): _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Total Salary Paid to you in the past 12 months: $ ________________________________ 2. Public Assistance received by you in the past twelve months: $________________________________________ 3. Total assets, excluding family furnishings: $_______________________________________________________ 4. Bank balances: $_________________________________________ 5. Number of Dependents: ___________________________________ Attach a copy of your federal income tax return from the previous year. If you did not file a federal income tax return during the previous year, state the reason why: _______________________________________________________________________________________ _______________________________________________________________________________________ AFFIDAVIT OF INDIGENCY I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge, and I further attest that I am without sufficient funds to pay the fees required for filing a civil action in the Franklin County Court of Common Pleas. ___________________________________________________________ AFFIANT’S SIGNATURE ___________________________________________________________ ADDRESS ___________________________________________________________ CITY, STATE, ZIP CODE NOTARY PUBLIC: Subscribed and duly sworn before me according to law, by the above named applicant this ___________ day of _________________, 20_____. ________________________________________________ NOTARY SIGNATURE American LegalNet, Inc. www.USCourtForms.com