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)