Affidavit In Support Of Request To Proceed In Forma Pauperis printable pdf download

Affidavit In Support Of Request To Proceed In Forma Pauperis

APPENDIX B (L.R. 5.01)

IN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIO

In the matter of

CASE NO:

Indigency of:

AFFIDAVIT IN SUPPORT OF

_____________________________

REQUEST TO PROCEED

IN FORMA PAUPERIS

(Applicant Name)

: : : : : : :

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.

Are you employed?

Yes______No______

If you answered “Yes”:

(1) What is the name and address of your employer?

______________________________________________________

(2)

How much do you earn per month?

______________________________________________________

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______

Appendix

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Affidavit In Support Of Request To Proceed In Forma Pauperis