PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the GUARDIANSHIP of:___________________________________________________ Case No. _____________________________ Date:_______________________ AFFIDAVIT OF INDIGENCY I, ____________________________________________, being duly sworn, say: 1. I wish to be appointed guardian of ______________________________________ who is an incompetent. 2. The ward is without funds or property readily available to pay attorney fees. 3. The ward is financially unable to retain private counsel without substantial hardship to himself/herself or his/her family. 4. I understand that I must inform the assigned counsel if the ward’s financial situation should change before the disposition of this case. 5. I understand that I am subject to criminal charges for providing false information. 6. I understand that if it is determined by the county, or by the Court, that the legal representation that was provided for the ward to which he/she was not entitled, he/she 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. _________________________________ Applicant Sworn before me and subscribed in my presence this _______ of ____________________, 20____. (Seal) _________________________________ Notary FORM 17.A - AFFIDAVIT OF INDIGENCY Crensch$\forms\17.A.doc 1/30/01 American LegalNet, Inc. www.USCourtForms.com