APPENDIX B (L.R. 5.01)
IN THE COMMON PLEAS COURT, BUTLER COUNTY, OHIO
In the matter of
AFFIDAVIT IN SUPPORT OF
REQUEST TO PROCEED
IN FORMA PAUPERIS
: : : : : : :
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?
If you answered “Yes”:
(1) What is the name and address of your employer?
How much do you earn per month?
If you answered “No”:
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? ________________________
What is your marital status? Single______Married______