Affidavit Of Indigency

IN THE COURT OF APPEALS OF OHIO SEVENTH APPELLATE DISTRICT ___________________ COUNTY ) Case No. __________________ ) __________________________________ ) ) Plaintiff(s)-Appell_____(s) ) ) AFFIDAVIT OF INDIGENCY VS. ) ) __________________________________ ) ) __________________________________ ) ) Defendant(s)-Appell_____(s). ) ) I, _______________________________________________, being duly sworn, state: 1. 2. I am financially unable to retain private counsel without substantial hardship to me or my family. I understand that I must inform the public defender or appointed attorney if my financial situation should change before the disposition of the case(s) for which representation is being provided. I understand that if it is determined by the county or the court that legal representation should not have been provided, I may be required to reimburse the county for the costs of representation provided. Any action filed by the county to collect legal fees hereunder must be brought within two years from the last date legal representation was provided. I understand that I am subject to criminal charges for providing false financial information in connection with this application for legal representation, pursuant to Ohio Revised Code sections 120.05 and 2921.13. I hereby certify that the information I have provided is true to the best of my knowledge. _______________________________________ Affiant's signature Sworn to and subscribed in my presence this _____ day of ________________, 20 ___. __________________________________ 3. 4. 5. _______________________________________ NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com