Affidavit In Support Of Request To Proceed In Forma Pauperis Page 3

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Property
Value
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
VII.
List all your creditors, including banks, loan companies, charge accounts, personal loans,
rent, utilities, child support, etc., and the amount you pay each month on each
bill/obligation.
Creditor
Amount Owed
___________________________________________________________
___________________________________________________________
___________________________________________________________
VIII. State your address and a phone number where the court can reach you:
___________________________________________________________
___________________________________________________________
___________________________________________________________
_____________________________
(Signature of Plaintiff)
STATE OF OHIO)
) ss:
BUTLER COUNTY)
Sworn to and signed before me this _____ day of __________,
20_____.
_____________________________
Notary Public
CERTIFICATE OF ATTORNEY
I have examined the answers given by my client in this questionnaire and to the best of
my knowledge and belief, the answers are true and accurate.
_____________________________
(Attorney's Signature)
Appendix
Page 4

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