FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY I. Name/Applicant PERSONAL INFORMATION Party Represented (if applicant, enter “same”) Mailing Address City State D.O.B. Zip Case No. II. Name 1) D.O.B. OTHER PERSONS LIVING IN HOUSEHOLD Relationship Name D.O.B. 3) Relationship 2) 4) III. MONTHLY INCOME/EMPLOYMENT INFORMATION Applicant Spouse Other Household Members Type of Income Employment (Gross) Unemployment Worker’s Comp. Pension/Social Security Child Support Works First/ TANF Disability Other Employer’s Name (for all household members) A. Total TOTAL INCOME $ Employer’s Address Phone IV. ALLOWABLE EXPENSES Type of Expense Amount Child Support Paid Out Child Care (if working only) Transportation for Work Insurance Medical/Dental Medical & Associated Costs of Caring for Infirm Family Members V. TOTAL INCOME Total Income – Allowable Expenses = Adjusted Total Income A. - TOTAL INCOME $ B. EXPENSES $ $ B. EXPENSES Type of Asset Real Estate / Home Stocks / Bonds /CD’s Automobiles Truck / Boats / Motorcycles Other Valuable Property Cash on Hand Money Owed to Applicant Other Checking Acct. (Bank / Acct.#) Savings/MM Acct. (Bank / Acct.#) C. ADJUSTED TOTAL INCOME $ VI. ASSET INFORMATION Describe/Length of Ownership/Make, Model, Year (where applicable) Price:$ Date Purchased: Amt. Owed:$ D. Estimated Value TOTAL ASSETS $ 1 American LegalNet, Inc. www.FormsWorkFlow.com VII. MONTHLY LIABILITIES/OTHER EXPENSES Type of Liability Amount Rent / Mortgage Food Electric Gas Fuel Telephone Cable Water / Sewer / Trash Credit Cards Loans Taxes Owed Other E. LIABILITIES & OTHER EXPENSES IX. VIII. GRAND TOTALS C. ADJ. TOTAL INCOME D. TOTAL ASSETS E. LIABILITIES & OTHER AFFIDAVIT OF INDIGENCY I, ___________________________________ (affiant) being duly sworn, say: 1. I am financially unable to pay court costs without substantial hardship to me or my family. 2. I understand that I must inform the Court if my financial situation should change before the disposition of the case(s) for which waiver of costs is being requested. 3. I understand that if it is determined by the county, or by the Court, that court costs should not have been waived, I may be required to reimburse the county for the costs of filing this action. 4. I understand that I am subject to criminal charges for providing false financial information in connection with the above application for waiving court costs pursuant to Ohio Revised Code Section 2921.13. 5. I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge. ______________________________________ Affiant’s Signature Date Notary Public/Individual duly authorized to administer oath: Subscribed and duly sworn before me according to law, by the above-named applicant this ____ day of _____________________, ______, at ______________________, County of ___________________ and State of _______________. ______________________________________ ______________________________________ Signature of person administering oath Title 12/2009 Form DR-105-B 2 American LegalNet, Inc. www.FormsWorkFlow.com