Poverty Affidavit And Order Court Appointed Counsel

Revised 2/18/09 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO ____________________________________________ ____________________________________________ ____________________________________________ EMPLOYER:________________________________ PETITIONER/PLAINTIFF VS. ____________________________________________ ____________________________________________ ____________________________________________ EMPLOYER:________________________________ PETITIONER/DEFENDANT/RESPONDENT ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) CASE NO._______________________ JUDGE BETH A. SMITH POVERTY AFFIDAVIT AND ORDER (Court Appointed Counsel in Contempt Actions) I, _____________________________________________, being duly sworn, says: 1. 2. 3. I am an indigent person entitled to legal representation in this case. I have completed the requisite Financial Disclosure/Affidavit of Indigency attached hereto. Pursuant to Ohio Revised Code 120.36(A), I respectfully request that the Court grant a waiver of the application fee for legal representation because I am indigent and unable to pay an application fee of $25.00, or because I will suffer an undue hardship if the fee is assessed. The reason I am unable to pay is as follows: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________. _____________________________________ Affiant Sworn before me and subscribed in my presence this _____ day of _____________________, 20___. ______________________________________ Notary Public ORDER Pursuant to ORC 120.36, the $25.00 Application Fee for private appointed counsel shall be: __________ Paid by the person to the Clerk of Courts. __________ Waived by the Court due to lack of resources or undue hardship. ________________________________ MAGISTRATE/JUDGE American LegalNet, Inc. www.FormsWorkflow.com