AO239 (4/13) N.D.OHIO United States District Court NORTHERN DISTRICT OF OHIO ____________________, Plaintiff v. ____________________, Defendant(s) APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT CASE NUMBER: JUDGE: I, ______________________________, swear or affirm under penalty of perjury that I am the (check appropriate box) petitioner/plaintiff/movant other in the above-named proceeding, that I am unable to pay the costs of these proceedings, and that I believe I am entitled to the relief sought in the complaint/petition/motion. I further swear or affirm under penalty of perjury under United States laws that my answers on this form and any attachments are true and correct. Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0", "none," or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name and the question number. NOTE: You should be prepared to provide the Court with copies of documents that support or verify all of your answers to the questions in this application. A PRISONER seeking to proceed without prepayment of fees shall submit an affidavit stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional office showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, attach one certified statement of each account. (Prisoner Financial Application available at http://www.ohnd.uscourts.gov/home/pro-se-information/) Signed: ________________________________ Print your Name: ______________________________ 1. State the address of your legal residence. (If incarcerated, state the place of incarceration and prisoner ID number.) _________________________________________________________________________________________________ Your daytime phone number: ___________________________ 2. For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Use gross amounts, that is the amounts before any deductions for taxes or otherwise. Income Source Employment Self-employment Income from real property (such as rental income) Interest and dividends Gifts or inheritance Alimony Child support Retirement (such as social security, pensions, annuities, insurance) Average monthly amount during the past 12 months You Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount expected next month You $ $ $ $ $ $ $ $ Spouse $ $ $ $ $ $ $ $ Date: ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com AO239 (4/13) N.D. OHIO Disability (such as Social Security, insurance payments) Unemployment benefits Public assistance (such as welfare) Other (specify) _________________ _________________ Total Monthly Income $ Yes $ No $ Is your spouse currently employed? Yes Yes No No $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Yes No 3. Are you currently employed? If incarcerated: Are you currently employed by jail/prison/correctional facility? Do you receive payment from the jail/prison/correctional facility? 4. List your employment history, current or, if you are not currently employed, most recent employer first. (Gross monthly pay is calculated before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay $ $ $ 5. List your spouse's employment history, current or, if your spouse is not currently employed, most recent employer first. (Gross monthly pay is calculated before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay $ $ $ 6. How much cash do you and your spouse have? $ __________________ Below, state any money you or your spouse have in checking or savings accounts or in any other financial institution. If incarcerated, also include your prisoner accounts. Financial Institution Type of Account Amount You Have Amount Your Spouse Has $ $ $ $ $ $ 7. List the assets, and their values, that you own or your spouse owns. Do not list clothing and ordinary household furnishings. Asset a. Home b. Real Estate c. Motor Vehicle d. Motor Vehicle e. Other Assets (for example, stocks, bonds, securities or other financial instruments) f. Other Assets Description Make and Year: Model: Registration #: Make and Year: Model: Registration #: Value $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com AO239 (4/13) N.D.OHIO 8. State every person, business or organization owing you or your spouse money, and the amount owed. Who owes you or your spouse money? a. b. c. d. Amount owed to you $ $ $ $ Amount owed to your spouse $ $ $ $ 9. State the persons who rely on you or your spouse for support. Name (Initials Only for Minor Children) Relationship Age a. b. c. d. Amount Contributed Monthly for His/Her Support $ $ $ $ 10. Estimate your average monthly expenses. Show separately the amounts paid by your spouse. Adjust any amount that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Expense Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included? Yes No Is property insurance included? Yes No Utilities (electricity, heating fuel, water, sewer, telephone) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental expenses Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. Total Monthly Insurance (not deducted from wages or included in mortgage payments) Homeowner's or renters: Life: Health: Motor Vehicle: Other: Taxes (not deducted from wages or included in mortgage payments) (specify): ______________________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ You $ Spouse $ American LegalNet, Inc. www.FormsWorkFlow.com AO239 (4/13) N.D.OHIO ______________________________ Installment payments Motor Vehicle: Credit Card(s) (name): _________________________ _________________________ Department Store(s) (name): _________________________ _________________________ Other: ____________________ Alimony, maintenance, and support paid to others Regular expenses for the operation of business, profession, or farm (attach detailed statement) Other (specify): TOTAL MONTHLY EXPEN