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Affidavit Of Indigency For Court Costs 1.00 - Ohio
| Affidavit Of Indigency For Court Costs Form. This is a Ohio form and can be used in Domestic Relations Ashland County (Court Of Common Pleas) . |
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IN THE COURT OF COMMON PLEAS, ASHLAND COUNTY, OHIO GENERAL AND DOMESTIC RELATIONS DIVISION ___________________________________, Plaintiff/Petitioner, vs./and ___________________________________, Defendant/Petitioner. AFFIDAVIT OF INDIGENCY FOR COURT COSTS Now comes ___________________________, and duly states: (1) I am not financially able to make a deposit of court costs in this case and therefore I request that the Court waive the court cost deposit in this case; (2) I further state as follows: What kind of a house do you live in? Single family Double Apartment Mobile Home Other:________________ Do you own the place you live in or rent it? Own Rent Monthly payment? $_______________________________ Case No. ___________________________ 9 9 9 9 9 9 9 Do you own, or have a share of, any other real estate (building or land)? 9 No 9 Yes - Value $_____________________________ 9 No 9 Yes - Total value: $___________________ No Yes - List the following information for any vehicle you own: Do you own a car or truck? Make, Model and Year: _______________________________Value: $________________Monthly Payment: $_________ Do you own personal property (such as: TV, stereo, CD, VCR or other items)? Do you have a job? 9 9 9 No - List last employer ______________________________________ and last date worked______________ 9 Yes - List employer's name ____________________________________________and take-home pay $______________ Are you collecting a pension, unemployment, disability, social security or public assistance? 9 No 9 Yes - List the total amount $________________ and type of payment: __________________________________________________________ Are you married? 9 No 9 Yes: List spouse's employer _________________________________ and take-home pay $__________ Is anyone living in your household getting income? 9 No 9 Yes - List the amount $___________ and source of the income: ____________________________________________________________________________________________________ When is the last time you tried to borrow money from a bank or other lending agency? Year: _______ Amount: $________________ Do you know anyone who will loan you money (friends, family, employer, or other)? Do you have a bank account? 9 No 9 Yes - Amount: $_________________ 9 No 9 Yes - Balance: $_________________ Do you have any stocks, bonds, or other investments? 9 No 9 Yes - Amount: $_____________ Type:______________________ Do you have an IRA, 401(K) or pension fund? 9 No 9 Yes - Amount: $______________ Type:____________________________ _ The answers to the above questions are true and correct. I understand that I am furnishing the following information to the Court for an official proceeding. I know that if I lie, I can be charged with the crime of Falsification (O.R.C. Section 2921.13) and that the punishment is up to 6 months in jail and a fine of up to $1,000. _______________________________________ Signature of Party Sworn to and subscribed before me this ________ day of ________________________, ________. 9 Approved 9 Denied ______________________________________________ Judge/Magistrate Date __________________________________________ Notary Public Page 1 of 1 FORM 1.00 (Eff. 3/1/2011) American LegalNet, Inc. www.FormsWorkFlow.com
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