IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS __________________________ DOB: ____________________ Plaintiff/Petitioner CASE NO. _____________ JUDGE HURLEY v. __________________________ DOB: ____________________ Defendant/Petitioner POVERTY AFFIDAVIT [R.C. 2323.30, 2323.31 and D.R. Rule 1.04] I, _______________________________, being duly sworn, says: 1. I am a party in the foregoing action; 2. I am without the funds or assets to give security or a cash deposit to secure costs at this time; 3. I understand that I must inform the Court if my financial situation should change before the disposition of my case; 4. I understand that I am subject to criminal charges for providing false information; 5. I understand that if it is determined by the Court, that I was not entitled to the suspended deposit/cost that were provided to me, I may be required to reimburse the county for the costs. 6. I understand that the Court will ultimately determine which party will be responsible for the payment of costs in this case, unless costs are waived. _____________________________ signature Sworn before me and subscribed in my presence this ____ day of __________________, _____. ___________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com ATTORNEY CERTIFICATION (required if affiant is represented by counsel): I, __________________________, Attorney at Law, certify that based on my inquiry and the information available to me, that the foregoing statements are true. I further certify that I am/not being paid by the affiant for the services in the above- mentioned case in the amount of $___________. I further understand that I am under a continuing obligation to advise the Court of any change in the financial status of my client. ___________________________ Signature of Attorney ___________________________ address ___________________________ address ___________________________ phone number ___________________________ Supreme Court Number (02/05) American LegalNet, Inc. www.FormsWorkFlow.com