Poverty Affidavit And Order

IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO ____________________________________________ ____________________________________________ ____________________________________________ EMPLOYER:________________________________ PETITIONER/PLAINTIFF VS. ____________________________________________ ____________________________________________ ____________________________________________ EMPLOYER:________________________________ PETITIONER/DEFENDANT/RESPONDENT ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) Revised 10/1/06 CASE NO._______________________ JUDGE BETH A. SMITH POVERTY AFFIDAVIT AND ORDER I, ____________________________, being duly sworn, says: 1. 2. 3. 4. 5. 6. I am a party in the foregoing action; I am without the funds or assets to give security or a cash deposit to secure costs at this time and have completed the requisite Financial Disclosure Form. I understand that I must inform the court if my financial situation should change before the disposition of my case; I understand that I am subject to criminal charges for providing false information; I understand that if it is determined by the Court that I was not entitled to the suspended deposit/costs that were provided to me, I may be required to reimburse the county for the costs; I understand that the Court will ultimately determine which party will be responsible for the payment of costs in this case, unless costs are waived. _____________________________________ Affiant Sworn before me and subscribed in my presence this _____ day of _____________________, 20___. ______________________________________ Notary Public ATTORNEY CERTIFICATION (required if affiant is represented by counsel): I, _________________________, Attorney at Law, certify that based on my inquiry and the information available to me, the foregoing statements are true; I further certify that I am not being paid by the affiant for my services in the above captioned case OR have agreed to only accept a fee in the amount of $___________________. I further understand that I am under a continuing obligation to advise the Court of any change in the financial status of my client. ________________________________ Attorney 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