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Poverty Affidavit And Order Form. This is a Ohio form and can be use in Mahoning County (Court Of Common Pleas).
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Tags: Poverty Affidavit And Order, Ohio County (Court Of Common Pleas), Mahoning
Revised 2/18/09
IN THE COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
MAHONING COUNTY, OHIO
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EMPLOYER:________________________________
PETITIONER/PLAINTIFF
VS.
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EMPLOYER:________________________________
PETITIONER/DEFENDANT/RESPONDENT
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CASE NO._______________________
JUDGE BETH A. SMITH
POVERTY AFFIDAVIT
AND
ORDER
(Seeking Waiver of Filing Fee/Cash Deposit)
I, _____________________________________________, being duly sworn, says:
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I am a party to the foregoing action.
I am without the funds or assets to give security or a cash deposit to secure costs at this time and have completed the
requisite Affidavit of Income, Expenses and Financial Disclosure attached hereto.
I understand that I must inform the court if my financial situation should change before the
disposition of my case;
I understand that I am subject to criminal charges for providing false information;
I understand that if it is determined by the Court that I was not entitled to the suspended deposit/costs
that were provided to me, I may be required to reimburse the county for the costs;
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.
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Affiant
Sworn before me and subscribed in my presence this _____ day of _____________________, 20___.
______________________________________
Notary Public
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, the foregoing statements are true; I further certify that I am not being paid by the Affiant for my services in the above captioned
case OR have agreed to only accept a fee 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.
_____________________________________
Attorney
ORDER
Based on the demonstrated indigence, the requirement for cash deposit is waived at this time.
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MAGISTRATE/JUDGE
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