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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 Domestic Relations Lake County (Court Of Common Pleas) . |
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FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY I. PERSONAL INFORMATION Name Case No. D.O.B. 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 Relationship1) 3) 2) 4) III. MONTHLY INCOME/EMPLOYMENT INFORMATION Type of Income Self Spouse Household Members TotalEmployment (Gross) Unemployment Workers Comp. Pension Social Security Child Support Works First/TANF Disability Other Other Employers Name (for all household members) SUBTOTAL A $ Address Phone ( ) IV. ALLOWABLE EXPENSES V. TOTAL INCOME Type of Expense 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 Of Caring for Infirm Family GRAND TOTAL C $ Members SUBTOTAL B $ VI. ASSET INFORMATION Type of Asset Describe / Length of Ownership / Make, Model, Year (where applicable) Estimated ValueReal Estate / Home Price:$ Date Purchased: Equity: Stocks / Bonds / CDs Automobiles Trucks / Boats / Motorcycles Other Valuable Property Cash on Hand Money Owed to Applicant 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 s hould 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 to for me to which I was not entitled, I may be required to rei mburse the county for the costs of representation provided. Any action filed by the county to collect l egal fees hereunder must be brought within two years form 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 2921.13. 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 this ______ day 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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