IN THE COMMON PLEAS COURT O F GREENE COUNTY, OHIO DOMESTIC RELATIONS DIVISION PLAINTIFF -vs- DEFENDANT CASE NO. AFFIDAVIT O F POVERTY ,Being first duly sworn and cautioned, deposes and says that helshe is the PLAINTIFFDEFENDANT in the above cause, that said case is brought in the Common Pleas Court of Greene County. That said PLAINTIFFIDEFENDANT is without sufficient financial means to prepay or give security for the costs in said action. PLAINTIFFIDEFENDANT further says that helshe has no money with which to pay the costs in said cause, or deposit with the clerk to cover costs in said action; that said PLAINTIFFDEFENDANT has no real or personal property with which to secure payment of said costs that may accrue, nor is said PLAINTIFFDEFENDANT able to give bond or any other security to cover said costs as provided by law. PLAINTIFFIDEFENDANT Sworn and subscribed before me this day of 20 NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com . IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS Case No. PlaintifflPetitioner DOB: Address: ObligorlObligee CSEA No. JUDGE STEVEN L. HURLEY DefendantlPetitioner DOB: Address: Affidavit of Income and Expenses and Financial Disclosure ObligorIObligee State of Ohio, SS: Now comes states as follows: , AffiantJPetitioner herein, being first duly cautioned and sworn and 1.TEMPORARY ORDERS (please check all that apply) -I do not request a temporary order I request a temporary order for - custody, A Domestic Violence Order under Case No. A Bankruptcy action under Case No. child support, andlor -spousal support. was filed on was filed on -The parties are presently residing together. II. CHILDREN OF THIS MARRIAGE 1. , DOB residing with 2. , DOB residing with 3. , DOB residing with 4. , DOB residing with 111. DOMESTIC VIOLENCE SCREENING (ORC SEC. 3109.052) 1. Has either Parent been convicted of domestic violence or any other offence involving physical harm or the threat of physical harm to a victim who is named in this affidavit or has been found to have engaged in child abuse? YES -(Plaintiff) (Defendant) NO 2. Is either party the subject of a Protection Order in Ohio or any other State? YES -(Plaintiff) (Defendant) NO American LegalNet, Inc. www.FormsWorkFlow.com IV.WAGES, EARNING A N D INCOME (Put your yearly and best estimate of the other Petitioner) A. Gross Yearly Income From Employment (Including self-employment) PlaintiffEirst Petitioner $ Defendandsecond Petitioner (Actual/Estimated).Based yearly Wages.(Actual/Estimated) $ .............. Employer. .............. ......... Payroll Address.. ...... ........ City, State, Zip.. . . . . . B. Other Yearly Income - Defined as Interest Dividend Income, Unemployment Compensation, Workers Compensation, Social Security or other disability benefits, Social Security/Pension Income, etc. Plaintifmirst Petitioner Source of Income Yearly Amount Defendandsecond Petitioner Source of Income Yearly Amount Please note - Wage earners must attach a copy of their most recent wage-earning statemendpay stub. Self-employed individuals must attach a copy of Schedule C of IRS Form 1040 from most recent tax reporting period. V. ASSETS AND LIABILITIES (Use additional sheet if necessary) 1. Retirement Benefits: Name and Address of Retiremenflension Plan 2 . Real Estate: Address of Property Present Value Present Value Name on Deed 3. Financial Accounts: List all bank, savings and loan, credit union, regulated Investment Company, mutual fund, bonds, securities, stocks, certificates of deposit, individual retirement accounts and all other financial accounts wherein you possess any interest. Name of Financial Institution Address Names Value American LegalNet, Inc. www.FormsWorkFlow.com 4 . LinbilitiesLDebt: (Monthly Installment Payments, i.e. Car Payments, Loans, etc.. .) Name of Creditor Purpose of Debt Payment Balance Due VI. AFFLANTE'ETITIONER'S MONTJXLY LIVING EXPENSES: List your actual expense for your present household only. Do not duplicate expenses previously listed in this affidavit. If the children are living with you, calculate expenses below for you and the children combined. A. Monthly Expenses I . Housing Rent or Mortgage (including taxes and insurance). ................................................. $ a. Gas & Electric (level billing or average per month). ...........................................$ b. Water and Sewer.. .................................................................................. $ c. Telephone (excluding long distance). ............................................................ .$ d. Trash Collection.. .................................................................................... $ e. Other ......................................................... .$ Housing Total .......................................................................................... $ 2. Other Monthly Expenses f. Child Care ............................................................................................$ g. Grocery (include food, laundry & cleaning products, etc.) ...................................$ h. Gasoline & Oil ...................................................................................... .$ i. Car repairs ............................................................................................ $ j. Insurance (auto, life, home) ........................................................................ $ k. Medical (not covered by insurance) ............................................................... $ I. Clothing ............................................................................................... $ m. Court ordered child support for children not of this marriage .................................$ n.. Other ........................................................... $ Other Monthly Expenses Total ..................................................................... .$ Total of I and 2 ......................................................................................... .$ American LegalNet, Inc. www.FormsWorkFlow.com VII. HEALTH INSURANCE: Plaintiffletitioner DefendantfRespondent Available Through Employment.. ...............YES / NO YES / NO.. .................. YES / NO.. ......................... Other Group Plan ............................YES / NO .................. Policy Number. ............ ......Employee Cost Per year for Individual Plan.. .... .......Employee cost Per Year for Family Plan ...... Affianeetitioner states that the information contained herein and attached hereto is complete and accurate to the best of hidher knowledge andor belief under penalty of law. Signature of Affianeetitioner Sworn to and subscribed in my presence this - NOTARY PUBLIC Signature of Attorney for AffiantFetitioner day of ,20-. My commission expires: Revised 9-4-2007 American LegalNet, Inc. www.FormsWorkFlow.com IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS __________________________ CASE NO. _____________ Plaintiff/Petitioner v. POVERTY AFFIDAVIT APPROVAL __________________________ Defendant/Petitioner __________________________________________________________________ The court hereby approves the filing of a Poverty Affidavit in lieu of a security deposit. APPROVED. ___________________________________ JUDGE American LegalNet, Inc. www.FormsWorkFlow.com