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Financial Disclosure-Affidavit Of Indigency - Ohio
| Financial Disclosure-Affidavit Of Indigency Form. This is a Ohio form and can be used in General Union County (Court Of Common Pleas) . |
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FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY I. PERSONAL INFORMATION I Name SS# D.O.B. a Mailing Address City State Zip Phone Residence (if different from above) Message Phone (within 48 hours) II. OTHER PERSONS LIVING IN HOUSEHOLD Name Age Relationship Name Age Relationship 1) 3) 2) 4) III. MONTHLY INCOME / EMPLOYMENT INFORMATION Type of Income Self Spouse Household Member TotalEmployment (Gross) Unemployment Workers Comp. Pension Social Security Child Support ADC Disability Food Stamps Other Employers Name (for all household members) SUBTOTAL A $ Address Phone IV. ALLOWABLE MONTHLY EXPENSES V. TOTAL INCOME Type of Expense0 - 0 6 - - Amount Child Support Paid Out Child Care (if working only) Total Monthly Income - Total Allowable Expenses = Total IncomeTransportation for Work Insurance SUBTOTAL A $ Medical / Dental -SUBTOTAL B -$ Medical & Associated Costs GRAND TOTAL C $ of Caring for Infirm Family Members SUBTOTAL B $ I VI. ASSET INFORMATION I - Type of Asset Describe / Length of Ownership / Make, Model, Year (where applicable)Estimated Value Real Estate / Home Stocks / Bonds / CDs Automobiles Trucks / Boats / Motorcycles Other Valuable Property Cash on Hand Money Owed to Defendant Other Checking Acct. (Bank / Acct. #) Savings Acct. (Bank / Acct. #) Credit Union (Name / Acct. #) GRAND TOTAL D $ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 VII. MONTHLY LIABILITIES / OTHER EXPENSES VIII. GRAND TOTALS Type of Liability Amount Rent / Mortgage Grand Total C Food Total Monthly Income Electric Gas Fuel Telephone Grand Total D Cable Total Assets Water / Sewer / Trash Credit Cards Loans Taxes Owed Total Monthly Liabilities Grand Total E Other and Other Expenses GRAND TOTAL E IX. AFFIDAVIT OF INDIGENCY I, being duly sworn, say: 1 . I am financially unable to retain private counsel without substantial ha rdship to me or my family. 2. I understand that I must inform my attorney if my financial situation sh ould change before the disposition of my case. 3. I understand that if it is determined by the county, or by the Court, th at legal representation was provided for me to which I was not entitled, I may be required to reimbu rse 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 pro vided. 4. I understand that I am subject to criminal charges for providing false f inancial information in connection with the above application for legal representation pursuant to Ohio Rev ised Code Sections 120.05 and 291.13(A)(13), (D)(4). 5. I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge. Clients Signature Date Notary Public: Subscribed and duly sworn before me according to law, by the above named applicant thisday of at , County of and State of Notarys Signature X. JUDGE CERTIFICATION I hereby certify that above-noted client is unable to fill out and/or si gn this financial disclosure/ affidavit for the following reason: I have determined that the applicant meets the criteria for receiving co urt appointed counsel. Judges Signature Date American LegalNet, Inc. www.USCourtForms.com
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