IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS ______________________ ______________________ ______________________ DOB: _________________ PLAINTIFF vs. ______________________ ______________________ ______________________ DOB: _________________ DEFENDANT ****************************************************************************************** I, __________________, being duly sworn, says: 1. 2. I am a party in the foregoing action; I am without the funds or assets to give security or a cash deposit to secure costs at this time; 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. CASE NO. _________________ JUDGE: _________________ POVERTY AFFIDAVIT [R.C. 2323.30, 2323.31 and Mont. D.R. Rule 4.04(B)] 3. 4. 5. American LegalNet, Inc. www.FormsWorkFlow.com 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 OF AFFIANT Sworn before me and subscribed in my presence this _____ day of ______________, ______. __________________________ 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, that the foregoing statements are true I further certify that I am/am not being paid by the affiant for my services in the abovementioned 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. __________________________ __________________________ __________________________ __________________________ American LegalNet, Inc. www.FormsWorkFlow.com