DR-112 Rev COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO Case Number Plaintiff/Petitioner Vs/and Defendant/Petitioner Motion to Proceed Without Payment of Deposit for Court Costs I, (your name), move for an order granting the right to proceed without paying the court cost deposit. I am financially unable to pay the filing fee. My financial circumstances are outlined in the Affidavit of Poverty being filed with this Motion. I acknowledge that the Court may undertake further review of the issue of costs at any time and make a final determination regarding payment. I further understand that should this Court deny this motion, I must pay the required cost deposit or the case/motion may be dismissed. Your Signature American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL DISCLOSURE/ I. PERSONAL INFORMATION Name/Applicant Party Represented ( if applicant, enter 223same224) D.O.B. Mailing Address City State Zip Case No. II. OTHER PERSON S LIVING IN HOUSEHOLD Name 1) D.O.B. Relationship Name 3) D.O.B. Relationship 2) 4) III. MONTHLY INCOME/EMPLOYMENT INFORMATION Type of Income Applicant Spouse Other Household Members Total Employment (Gross) Unemployment Worker222s Comp. Pension/Social Security Child Support Works First/ TANF Disability Other Employer222s Name (for all household members) A. TOTAL INCOME $ Employer222s Address Phone IV. ALLOWABLE EXPENSES V. TOTAL INCOME Type of Expense Amount Total Income 226 Allowable Expenses = Adjusted Total Income Child Support Paid Out Child Care (if working only) Transportation for Work Insurance Medical/Dental A. TOTAL INCOME $ Medical & Associated Costs of Caring for Infirm Family Members - B. EXPENSES $ B. EXPENSES $ C. ADJUSTED TOTAL INCOME $ VI. ASSET INFORMATION Type of Asset Describe/Length of Ownership/Make, Model, Year (where applicable) Estimated Value Real Estate / Home Price:$ Date Purchased: Amt. Owed:$ Stocks / Bonds /CD222s Automobiles Truck / Boats / Motorcycles Other Valuable Property Cash on Hand Money Owed to Applicant Other Checking Acct. (Bank / Acct.#) Savings/MM Acct. (Bank / Acct.#) D. TOTAL ASSETS $ American LegalNet, Inc. www.FormsWorkFlow.com VII. MONTHLY LIABILITIES/OTHER EXPENSES VIII. GRAND TOTALS Type of Liability Amount C. ADJ. TOTAL INCOME D. TOTAL ASSETS E. LIABILITIES & OTHER Rent / Mortgage Food Electric Gas Fuel Telephone Cable Water / Sewer / Trash Credit Cards Loans Taxes Owed Other E. LIABILITIES & OTHER EXPENSES IX. 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 dispositionof 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 havebeen 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 connectionwith 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 ofmy knowledge. Affiant222s 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 American LegalNet, Inc. www.FormsWorkFlow.com