STATE OF OHIO, ___________________ COUNTY, SS: IN THE COURT OF COMMON PLEAS JUVENILE DIVISION CASE NO. _______________________ ________________________________ Plaintiff AFFIDAVIT OF INABILITY TO PREPAY OR GIVE SECURITY FOR COSTS vs. ________________________________ Defendant STATE OF OHIO ) ) ___________________________ COUNTY) SEC. 2323.31 REVISED CODE I, the undersigned, a party in the above captioned case, being first duly sworn, represent to the court that I am unable either to prepay or give security for costs in this action and request the Clerk to accept the attached pleading herein without prepaying or giving security for costs as provided by Sec. 2323.21 of the Revised Code. In support of this request, I submit answers to the following questions: 1. What is your age? 2. years. Do you have any children? If so, give names and ages. ______________________________________________________________________ __________________________________________________________________ 3. What is your occupation or business? _____________________________________ 4. Are you employed? If so, give names and addresses of your employer(s). _________________________________________________________ ____________________________________________________________________ 5. What did you earn during the past year? ___________________________________ 6. What are your parent’s names and ages? ___________________________________ ____________________________________________________________________ 12 American LegalNet, Inc. www.USCourtForms.com 7. Do you own any real estate? Is it mortgaged? If so, give its value ______________________ If so, give the mortgage ________________________ If so, what is the value? ___________ 8. Do you own an automobile? 9. What other thing(s) do you own? ________________________________________ What debts are against it (them)? ________________________________________ 10. Have you made an advance payment to your attorney for his services in this case?___ If so, how much? _________ Who paid it? ______________ 11. Do you have any securities or bank accounts? If so, give its value ___________ Are you receiving public assistance? _____________ How much? _______________ If so, what kind? STATE OF OHIO ) ) ___________________________ COUNTY) ______________________________________ Signature Before me a Notary Public personally appeared ____________________________, who being first duly cautioned and sworn, says the facts in the foregoing affidavit are true. ______________________________________ NOTARY PUBLIC 13 American LegalNet, Inc. www.USCourtForms.com