IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO GENERAL DIVISION Case No: Plaintiff, vs. Defendant. Affidavit of Indigency, Income, Expenses and Financial Disclosure. SSN: XXX - XX - ******************************************************************* STATE OF OHIO, SS: Now comes , afflant herein, and having been duly cautioned and sworn, states that he/she has been advised that this affidavit may be used for any or all of the following purposes: (1) to make complete disclosure of affiant's income, assets, liabilities and expenses. Minor and/or Dependent Children Supported: age age age age age is residing with is residing with is residing with is residing with is residing with American LegalNet, Inc. www.FormsWorkFlow.com 1. INCOME: A. Present Place of Employment: B. Length of Employment: 1. Monthly Take Home Pay: 2. If Out of work, how long: C. How have you supported yourself and/or family? (Other sources of income): to 1. Monthly amount: Total I: 11. MONTHLY HOUSEHOLD EXPENSES: A. Rent or Home Mortgage Payments: B. Food: C. Clothing: D. Medical and Dental: E. Utilities (DP&L, Phone, etc.)F. Alimony or Child Support: G. Insurance, describe: H. Other: Total II: American LegalNet, Inc. www.FormsWorkFlow.com III. ASSETS: A. Cash (incl. all bank accounts) describe: B. Tangible Personal Property (incl. cars, motorcycles, TV & stereo, jewelry, etc.): C. Real Estate, describe D. Intangible Personal Property (incl. stocks, bonds, notes, life insurance surrender value, business interest), describe: E. Other, describe: Total III: IV. LIABILITIES: A. Mortgages (incl. car, house, etc.) describe: B. Loans (incl. credit union, finance company, etc.), describe: C. Court fines or restitutions: American LegalNet, Inc. www.FormsWorkFlow.com D. Other indebtedness (incl. retailers, personal debts, etc.), describe: Total IV: SUMMARY Net Income: (Total I minus II): Net Income (Total III minus IV): Total: The undersigned Affiant, having been duly sworn, hereby alleges that he/she is indigent and is unable to pay the mandatory filing fees. Affiant Sworn to and subscribed in my presence on this day of Notary Public My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com