COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO _____________________ Plaintiff/Petitioner _____________________ Address _____________________ City ST ZIP _____________________ SS# DOB CASE NO. _______________ VS. _____________________ Defendant/Respondent _____________________ Address _____________________ City ST ZIP _____________________ SS# DOB POVERTY AFFIDAVIT ______________________, after being first duly sworn according to law, is financially and otherwise unable either to give security or to make a cash deposit for costs in the above-entitled action. 1. I currently reside at:______________________________________________ 2. I live with:______________________________________________________ 3. My source(s) of income is/are:______________________________________ 4. The household’s total monthly income is:_____________________________ 5. I have $__________ in savings or other financial account. 6. I believe I have good grounds to bring or defend this action. _____________________ AFFIANT SWORN to before me and SUBSCRIBED in my presence this ______ day of ______________, 20____. _____________________ NOTARY PUBLIC Form DR-105 American LegalNet, Inc. www.USCourtForms.com