Affidavit Of Indigency

STATE OF OHIO, ___________________ COUNTY, SS: IN THE COURT OF COMMON PLEAS JUVENILE DIVISION ________________________________ Plaintiff CASE NO. _______________________ vs. AFFIDAVIT OF INDIGENCY ________________________________ Defendant STATE OF OHIO ) ) _________________________________ COUNTY) SEC. 2323.31 REVISED CODE I, the undersigned, a party in the above captioned case, being first duly sworn, represent to the court that I am unable either to prepay or give security for costs in this action and request the Clerk to accept the attached pleading herein without prepaying or giving security for costs as provided by Sec. 2323.21 of the Revised Code. By submitting this Affidavit of Indigency, you will be assessed a non-refundable $25.00 application fee unless waived or reduced by the Court. Pursuant to Tuscarawas County Juvenile Court Local Rule 2.2 no civil action or proceeding will be accepted for filing with an Affidavit of Indigency without the party filing first paying the $25.00 fee, unless this fee is waived by the Court. In support of this request, I submit the following information: I. INCOME 1. Income earned in past twelve months: Employer: Position: 2. Employed since: Hourly rate or salary: $ Income earned by spouse in past twelve months: Spouse's Employer: Position: Employed since: Hourly rate or salary: $ 3. 4. 5. Alimony/child support received: Public benefits received (ADC, SS, SSI, WC, etc.) Other income (pension, interest, etc.) American LegalNet, Inc. www.FormsWorkFlow.com II. ASSETS 1. Do you own any real estate? Mortgage payment (if any): $ 2. Do you own an automobile? Monthly payment: $ 3. What other thing(s) do you own? What debts are against it (them)? If so, what is the value? If so, give its value $ III. MAJOR DEBTS 1. Creditor: Monthly payment: $ 2. Creditor: Monthly payment: $ Amount owed: Amount owed: IV. FAMILY COMPOSITION 1. Number of people in your home that you support: Names, ages and relationship (spouse, child, parent, etc.) of the people you support: OATH OF AFFIANT STATE OF OHIO ) ) ___________________________ COUNTY) I hereby swear or affirm that the answers above are true, complete and accurate to the best of my knowledge. I understand that falsification of this document my result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury under Ohio Revised Code §2921.11. AFFIANT Sworn to and subscribed before me on this day of , NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com