FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCYI. PERSONAL INFORMATIONSS#D.O.B.NamePhoneMailing AddressCityStateZip()Residence (if different from above)Message Phone (within 48 hours)()II. OTHER PERSONS LIVING IN HOUSEHOLDNameAgeRelationshipNameAgeRelationship 1)3)4)2)III. MONTHLY INCOME / EMPLOYMENT INFORMATIONType of Income Employment (Gross) UnemploymentWorkers' Comp. PensionSocial Security Child Support ADCDisabilityFood Stamps OtherSpouseTotalSelfHousehold MembersCOURT COUNTY OFEmployer's Name (for all household members) AddressSUBTOTAL A$. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Phone()Calendar No.IV. ALLOWABLE MONTHLY EXPENSESV. TOTAL INCOMEJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)AmountType of Expense Child Support Paid Out Child Care (if working only) Transportation for Work InsuranceMedical / Dental Medical & Associated Costs of Caring for Infirm Family MembersTotal Monthly Income -Total Allowable Expenses = Total Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOSUBTOTAL A -SUBTOTAL B$ -$$GRAND TOTAL CGREETINGS:$SUBTOTAL BWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,VI. ASSET INFORMATIONlocated at County ofType of Asset Real Estate / Home Stocks / Bonds / CD's AutomobilesDescribe / Length of Ownership / Make, Model, Year (where applicable)Estimated Value, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20, on thenoon, and at any recessed in roomo'clock in the day ofYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Trucks Boats / Motorcycles Other Valuable Property Cash on Hand, one of the Justices of the, 20 County,day ofCourt in Witness, Honorable(Attorney must sign above and type name below)Money Owed to Applicant OtherChecking Acct. (Bank / Acct. #) Savings Acct. (Bank / Acct. #) Credit Union (Name / Acct. #)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:$GRAND TOTAL DMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OFVII. MONTHLY LIABILITIES / OTHER EXPENSESVIII. GRAND TOTALSType of LiabilityAmount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Rent / Mortgage FoodGrand Total CTotal Monthly IncomeCalendar No.ElectricGasFuelTelephoneCableWater / Sewer / Trash Credit Cards LoansTaxes Owed OtherJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Grand Total DTotal Assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Grand Total ETotal Monthly Liabilities and Other ExpensesTHE PEOPLE OF THE STATE OF NEW YORK TOGRAND TOTAL EIX. AFFIDAVIT OF INDIGENCYI,being duly sworn, say:GREETINGS:1.I am financially unable to retain private counsel without substantial hardship to me or my family. 2.I understand that I must inform my attorney of my financial situation should change before the disposition of my case. 3.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,I understand that if it is determined by the county, or by the Court, that legal representation was provided for me to which I was not entitled, 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. 4.located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomI understand that I am subject to criminal charges for providing false financial information in connection with the above application for legal representation pursuant to Ohio Revised Code Sections 120.05 and 2921.13(A)(13), (D)(4). 5.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.I hereby certify that the information I have provided on this financial disclosure from is true to the best of my knowledge., one of the Justices of theClient's SignatureDateCourt in Witness, Honorableday of, 20 County,Notary Public: Subscribed and duly sworn before me according to law, by the above named applicant thisday of , 19(Attorney must sign above and type name below)at.and State of, County ofNotary's SignatureAttorney(s) forIX. AFFIDAVIT OF INDIGENCYOffice and P.O. AddressI hereby certify the above-noted client is unable to fill out and/or unable to sign this financial disclosure/affidavit for the following reason:. I have determined that the applicant meets the criteria for receiving court appointed counsel.Telephone No.: Facsimile No.: E-Mail Address:DateJudge's SignatureMobile Tel. No.:OPD-206R (4/96)American LegalNet, Inc. www.USCourtForms.com
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