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Affidavit Of Indigency For Court Costs Form. This is a Ohio form and can be use in Ashland County (Court Of Common Pleas).
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Tags: Affidavit Of Indigency For Court Costs, 1.00, Ohio County (Court Of Common Pleas), Ashland
IN THE COURT OF COMMON PLEAS, ASHLAND COUNTY, OHIO GENERAL AND DOMESTIC RELATIONS DIVISION Case No. Plaintiff/Petitioner, vs./and Defendant/Petitioner. AFFIDAVIT OF INDIGENCY FOR COURT COSTS Now comes , and duly states: (1) I am not financially able to make a deposit of court costs in this case and therefore I request that the Court waive the court cost deposit in this case; (2) I further state as follows: Single family Double Apartment Mobile Home Other: What kind of house do you live in? Do you own the place you live in or rent it? Own Rent Monthly payment? $ Do you own, or have a share of, any other real estate (building or land)? No Yes Value $ Do you own a car or truck? No Yes List the following information for any vehicle you own: Make, Model and Year: Value : $ Monthly Payment: $ Do you own personal property (such as: TV, stereo, CD, VCR or other items? No Yes Total Value $ Do you have a job? No List last employer Last day worked Yes List employer's name Take-home pay $ Are you collecting a pension, unemployment, disability, social security or public assistance? No Yes List the total amount $ and type of payment: Are you married? No Yes: List spouse's employer: Take-home pay $ Is anyone living in your household getting income? No Yes List the amount $ and source of income: When is the last time you tried to borrow money from a bank or other lending agency? Year: Amount $ Do you know anyone who will loan you money (friends, family, employer, or other)? No Yes - Amount $ Do you have a bank account? No Yes - Balance: $ Do you have any stocks, bonds, or other investments? No Yes Amount $ Type: Do you have an IRA, 401(K) or pension fund? No Yes Amount $ Type: The answers to the above questions are true and correct. I understand that I am furnishing the following information to the Court for an official proceeding. I know that if I lie, I can be charged with the crime of Falsification (O.R.C. Section 2921.13) and that the punishment is up to 6 months in jail and a fine of up to $1,000. _____________________________________ Signature of Party Sworn to and subscribed before me this day of , . Approved Denied __________________________________________ Notary Public Judge/Magistrate Page 1 of 1 Date American LegalNet, Inc. www.FormsWorkFlow.com FORM 1.00 (Eff. 3/1/2017)