IN THE PROBATE COURT OF MONTGOMERY COUNTY, OHIO Plaintiff, vs. POVERTY AFFIDAVIT (R.C. 2323.31) AND ENTRY Defendant(s) ____________________________________________________________ I, ____________________________, being first duly sworn, depose that I am the Plaintiff in the above-captioned action and that I am unable by reason of poverty to pay the deposit to secure costs required of this action. In support of my request that the Court accept my claim for filing without the payment of the deposit to secure costs, I state the following: 1. I (am) (am not) employed. (If employed) My salary or wages are _________ per month. My employer is _________________________________________________ _. (Expenses) My expenses each month are _________________________. 2. I (have) (have not) received within the last twelve months income from a business, profession, or other self-employment, or rents, interest, dividends, or other sources of income. (The amount and source of income received were: ___________________________________________________.) 3. I (own) (do not own) cash or savings. (The value of property owned is ___________________________________________________.) 4. I (own) (do not own) real estate, stocks, bonds, notes, automobiles, or other property of value (excluding household goods) (The value of property owned is ___________________________________________________.) 5. The following persons are dependent upon me for their support: ___________________________________________________ ___________________________________________________ MONTGOMERY COUNTY PROBATE COURT FORM 3A American LegalNet, Inc. www.USCourtForms.com>>>> 2CASE NAME _______________________________ CASE NO. ___________________ I understand that a false statement or answer to any question in this affidavit will subject me to the penalties of perjury. ______________________________ A ffiant Subscribed and sworn to before me this ____ day of _________, 20__. _____________________________ (Deputy Clerk/Notary) ENTRY AUTHORIZING PAYMENT OF COURT COSTS This Court finds that the Plaintiff is unable to give a security or cash deposit as required by the rules of this court and orders that the Clerk shall accept the Plaintiffs Complaint for filing without the posting of a security deposit and the collection of costs shall be postponed until the case is terminated. ______________________________ J udge/Magistrate MONTGOMERY COUNTY PROBATE COURT FORM 3A American LegalNet, Inc. www.USCourtForms.com