IN THE PROBATE COURT OF MONTGOMERY COUNTY, OHIO GUARDIANSHIP OF ________________________________________ CASE NO. ____________________ AFFIDAVIT OF INDIGENCY (R.C. 2111.51) _____________________________________, the undersigned, being first duly sworn, says that the proposed ward is indigent and that the proposed wards estate is insufficient to pay the deposit to secure costs required to file this action. In support of this affidavit the undersigned states the following: 1. The proposed wards annual income is _________________________. 2. The proposed wards monthly expenses are _____________________. 3. The ward is responsible for the care of _______ persons. 4. The undersigned is not aware of any assets of the ward that have been transferred for less than fair market value in the past three years, except: ____________________________________________________. _______________________________ Affiant Sworn to and subscribed before me this _____ day of ___________, 20_____. ______________________________ (Notary Public/Deputy Clerk) ENTRY AUTHORIZING PAYMENT OF COURT COSTS This Court finds that the proposed ward is indigent and orders the costs of this action paid from the indigent guardianship fund. Any additional assets which come into the possession of the guardian, shall be reported to the Court and may be used to reimburse said fund for the costs of this action. ______________________________ J udge/Magistrate MONTGOMERY COUNTY PROBATE COURT FORM 3B