IN THE MUNICIPAL COURT OF PORTAGE COUNTY, OHIO CIVIL DIVISION Case No. Plaintiff Defendant Name: Address: OTHER PERSONS LIVING IN HOUSEHOLD Name: Age: Relationship: Name: Age: Relationship: Name: Age: Relationship: MONTHLY INCOME/EMPLOYMENT INFORMATION GROSS INCOME (before taxes) SELFSPOUSEHOUSEHOLDMEMBERS TOTAL Employment$ Unemployment$ Workers222Comp$ Pension$ SocialSecurity$ ChildSupport$ ADC$ Disability$ FoodStamps$ Other$ TOTAL $$$$ AFFIDAVIT OF INDIGENCY STATE OF OHIO COUNTY OF PORTAGE, ss: , being first sworn, deposes and says that (s)he is a party in the above entitled cause; that said cause is brought in the Municipal Civil Division of Portage County, Ohio and that (s)he is: employed unemployed a recipient of ADC/SSI/SSD and is without sufficient financial means to prepay or give security for the costs of said action. Affiant further says that (s)he has no money with which to pay the costs of said action; that (s)he has no available real property or personal property with which to secure the payment of said costs that may accrue; nor is (s)he able to give bond or any other security to cover said costs as provided by law. I understand that the security for costs is only being deferred, and I may be required to pay the costs associated with this action at a later date. I hereby certify that the information provided herein is true to the best of my knowledge. Affiant Sworn to before me and subscribed in my presence this day of , 20. Notary Public Judge Warning: This document is an official Court Document. You are making this affidavit under oath . FALSE STATEMENTS are p otentiall y p er j ur y , and ma y sub j ect y ou to criminal p enalties. American LegalNet, Inc. www.FormsWorkFlow.com