Applicant's Name Mailing Address Case No. ($25.00 application fee may be assessed--see notice on reverse side) I. PERSONAL INFORMATION D.O.B. Person Represented's Name (if juvenile) City Phone ( ) II. OTHER PERSONS LIVING IN HOUSEHOLD Relationship Name 3) State Cell Phone ( ) D.O.B. FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY D.O.B. Zip Code Name 1) 2) D.O.B. Relationship 4) III. PRESUMPTIVE ELIGIBILITY The appointment of counsel is presumed if the person represented meets any of the qualifications below. Please place an `X' Ohio Works First / TANF: ____ SSI: ____ SSD: ____ Medicaid: ____ Poverty Related Veterans' Benefits: ____ Food Stamps: ____ Refugee Settlement Benefits: ____ Incarcerated in state penitentiary: ____ Committed to a Public Mental Health Facility: ____ Other (please describe): ____________________________________________________________ IV. INCOME AND EMPLOYER Applicant Gross Monthly Employment Income Unemployment, Worker's Compensation, Child Support, Other Types of Income TOTAL INCOME $ Employer's Name:______________________________________________________ Phone Number: ______________________________ Employer's Address: ________________________________________________________________________________________________ Type of Asset Checking, Savings, Money Market Accounts Stocks, Bonds, CDs Other Liquid Assets or Cash on Hand V. LIQUID ASSETS Estimated Value $ $ $ Total Liquid Assets $ VI. MONTHLY EXPENSES Amount Type of Expense Telephone Transportation / Fuel Taxes Withheld or Owed Credit Card, Other Loans Utilities (Gas, Electric, Water / Sewer, Trash) Other (Specify) EXPENSES $ EXPENSES $ Spouse (Do not include spouse's income if spouse is alleged victim) Juvenile: ____ (if juvenile, please continue at Section VIII) Total Income Type of Expense Child Support Paid Out Child Care (if working only) Insurance (medical, dental, auto, etc.) Medical / Dental Expenses or Associated Costs of Caring for Infirm Family Member Rent / Mortgage Food Amount VII. DETERMINATION OF INDIGENCY If applicant's Total Income in Section IV is at or below 187.5% of the Federal Poverty Guidelines, counsel must be appointed. For applicants whose Total Income in Section IV is above 125% of the Federal Poverty Guidelines, see recoupment notice in Section XI. If applicant's Liquid Assets in Section V exceed figures provided in OAC 120-1-03, appointment of counsel may be denied if applicant can employ counsel using those liquid assets. If applicant's Total Income falls above 187.5% of Federal Poverty Guidelines, but applicant is financially unable to employ counsel after paying monthly expenses in Section VI, counsel must be appointed. American LegalNet, Inc. www.FormsWorkFlow.com VIII. $25.00 APPLICATION FEE NOTICE By submitting this Financial Disclosure / 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 entity that will make a determination regarding your indigency. No applicant may be denied counsel based upon failure or inability to pay this fee. IX. AFFIDAVIT OF INDIGENCY I, _______________________________________________(applicant or alleged delinquent child) being duly sworn, state: 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 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 from 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 this 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 ___________________________, State of Ohio. ______________________________________ Signature of person administering oath ___________________________________________ Title (example: Notary, Deputy Clerk of Courts, etc.) 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 party represented meets the criteria for receiving court-appointed counsel. _________________________________ ______________ Judge's signature Date ORC. §120.03 allows for county recoupment programs. Any such program may not jeopardize the quality of defense provided or act to deny representation to qualified applicants. No payments, compensation, or in-kind services shall be required from an applicant or client whose income falls below 125% of the federal poverty guidelines. See OAC 120-1-05. Through recoupment, an applicant or client may be required to pay for part of the cost of services rendered, if he or she can reasonably be expected to pay. See ORC §2941.51(D) XII. JUVENILE'S PARENTS' INCOME* ­ FOR RECOUPMENT PURPOSES ONLY ­ NOT FOR APPOINTMENT OF COUNSEL Custodial Parents' Income (Do not include parents' Total income if parent or relative is alleged victim) XI. NOTICE OF RECOUPMENT Employment Income (Gross) Unemployment, Workers Compensation, Child Support, Other Types of Income TOTAL INCOME $ *Please complete Section VI on page 1 of this form if you would like the court to consider your monthly expenses when determining the amount of recoupment which you can reasonably be expected to pay. American LegalNet, Inc. www.FormsWorkFlow.com OPD-206R rev. 01/2012 P.C. Docs. #353441