Affidavit In Support Of Request To Proceed In Forma Pauperis

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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.
I.
Are you employed?
Yes______No______
If you answered “Yes”:
A.
(1) What is the name and address of your employer?
______________________________________________________
______________________________________________________
(2)
How much do you earn per month?
______________________________________________________
If you answered “No”:
B.
(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
Page 2

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