FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY ($25.00 application fee may be assessed—see notice on reverse side) I. PERSONAL INFORMATION Party Represented (if applicant, enter “same”) Name/Applicant Mailing Address City Case No. Phone ( ) Name 1) 2) State ZIP Message Phone (within 48 hours) ( ) II. OTHER PERSONS LIVING IN HOUSEHOLD Relationship Name 3) D.O.B D.O.B. D.O.B Relationship 4) III. MONTHLY INCOME/EMPLOYMENT INFORMATION Spouse (or Parents if Other Household Applicant applicant is a juvenile) Members Type of Income Employment (Gross) Total Unemployment Worker’s Comp. Pension/Social Security Child Support Works First/TANF Disability Other Employer’s Name (for all household members) A. TOTAL INCOME $ Phone ( ) Employer’s Address IV. ALLOWABLE EXPENSES Type of Expense Amount Child Support Paid Out Child Care (if working only) V. TOTAL INCOME Total Income – Allowable Expenses = Adjusted Total Income Transportation for Work - Medical/Dental Medical & Associated Costs Of Caring for Infirm Family Members A. TOTAL INCOME B. EXPENSES $ C. ADJUSTED TOTAL INCOME Insurance $ B. EXPENSES $ Type of Asset Real Estate / Home $ VI. ASSET INFORMATION Describe / Length of Ownership / Make, Model, Year (where applicable) Price:$ Date Purchased: Amt. Owed:$ Estimated Value Stocks / Bonds / CD’s Automobiles Trucks / 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 Type of Liability VIII. GRAND TOTALS Amount Rent / Mortgage C. ADJ. TOTAL INCOME Food Electric D. TOTAL ASSETS Gas Fuel Telephone E. LIABILITIES & OTHER Cable $25.00 APPLICATION FEE NOTICE Water / Sewer / Trash Credit Cards Loans Taxes Owed Other E. LIABILITIES & OTHER EXPENSE By submitting this Financial Disclosure Form/Affidavit of Indigency Form, you will be assessed a non-refundable $25.00 application fee unless waived or reduced by the court. If assessed, the fee is to be paid to the clerk of courts within seven (7) days of submitting this form to the court, the public defender, your appointed counsel or any other party who will make a determination regarding your indigency. IX. AFFIDAVIT OF INDIGENCY I, _______________________________________________________(affiant) being duly sworn, say: 1. I am financially unable to retain private counsel without substantial hardship to me or my family. 2. I understand that I must inform the public defender or appointed attorney if my financial situation should change before the disposition of the case(s) for which representation is being provided. 3. I understand that if it is determined by the county, or by the Court, that legal representation should not have been provided, I may be required to reimburse the county for the costs of representation provided. Any action filed by the county to collect legal fees hereunder must be brought within two years form the last date legal representation was provided. 4. I understand that I am subject to criminal charges for providing false financial information in connection with the above application for legal representation pursuant to Ohio Revised Code Sections 120.05 and 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 X. JUDGE CERTIFICATION I hereby certify that above-noted applicant is unable to fill out and/or sign this financial disclosure/ affidavit for the following reason: ___________________________________________________________________. I have determined that the applicant meets the criteria for receiving court appointed counsel. Judge’s Signature OPD-206R rev. 9/2005 Date American LegalNet, Inc. www.FormsWorkflow.com