Revised 6/11/15 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO ______________________________ PLAINTIFF/PETITIONER VS/AND ______________________________ DEFENDANT/PETITIONER ) ) ) ) ) ) ) ) CASE NO. _________________ REQUEST FOR COURT-APPOINTED ATTORNEY I, ___________________________, hereby acknowledge receipt of the summons and order to appear as well as the motion and notice for the contempt hearing scheduled. I believe myself to be indigent and unable to retain counsel for the hearing. I hereby apply for a court-appointed attorney for representation. DATE: ____________________________ SIGNATURE ___________________________ ___________________________ Name and Address (print or type) ___________________________ ___________________________ Home Phone: _______________ Work Phone: _______________ PLEASE RETURN THIS FORM TO: MAHONING COUNTY DOMESTIC RELATIONS COURT Mahoning County Courthouse, 4th Floor 120 Market Street Youngstown, Ohio 44503 Attn: Aracelis American LegalNet, Inc. www.FormsWorkFlow.com