Financial Disclosure-Affidavit Of Indigency

FINANCIAL DISCLOSURE / AFFIDAIT OF INDIGENCY I. PERSONAL INFORMATION Name Mailing Address Residence (if different from above) City Case No. State Zip D.O.B. Phone ( ) Message Phone (within 48 hours) II. OTHER PERSONS LIVING IN HOUSEHOLD Name 1) 2) Type of Income Self Employment (Gross) Unemployment Worker's Comp. Pension Social Security Child Support Work First/TANF Disability Food Stamps Other Employer's Name (for all household members) Address Age Relationship Name 3) 4) Age Relationship III. MONTHLY INCOME/EMPLOYMENT INFORMATION Spouse Household Members Total Subtotal A Phone ( ) IV. ALLOWABLE EXPENSES Type of Expense Child Support Paid Out Child Care (if working only) Transportation for Work Insurance Medical/Dental Medical & Associated Costs of Caring for Infirm Family Members SUBTOTAL B Type of Asset Real Estate Stocks / Bonds / CD's 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#) Amount V. TOTAL INCOME Total Monthly Income ­ Total Allowable Expenses = Total Income SUBTOTAL A - SUBTOTAL B GRAND TOTAL C $ $ $ $ VI. ASSEST INFORMATION Describe / Length of Ownership / Make, Model, Year (where Applicable) Estimated Value GRAND TOTAL D $ American LegalNet, Inc. www.USCourtForms.com VII. MONTHLY LIABILITES/OTHER EXPENSES Type of Liability Amount Rent / Mortgage Food Electric Gas Fuel Telephone Cable Water / Sewer / Trash Credit Cards Loans VIII. GRAND TOTALS Grand Total C Total Monthly Income Grand Total D Total Assets Grand Total E Taxes Owed Other GRAND TOTAL E Total Monthly Liabilities And Other Expenses IX. AFFIDAVIT OF INDIGENCY I, _____________________________________________________ being duly sworn, say; 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 if my financial situation should change before the Disposition of my case. 3. I understand that if it is determined by the county, or by the Court, that legal representation was provided to me to which I was not entitled, I may be required to reimburse the county for the cost 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. I understand that I am subject to criminal charges for providing false 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. 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 Lancaster , County of Fairfield and State of Ohio. _________________________________ Notary's Signature My commission expires on X. JUDGE CERTIFICATION I hereby certify that above-noted client is unable to fill out and/or sign this financial disclosure/ affidavit for the following reason: ___________________________________________________. I have determined that the applicant meets the criteria for receiving court appointed counsel. ____________________________________ Judge's Signature Date American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com