The Ohio Judicial Center 65 South Front Street, Third Floor Columbus, OH 43215 614. 387.9800 or 1.800.824.8263 www.cco.state.oh.us Poverty Statement (Affidavit) Plaintiff V. Case Number Judge Defendant I, , state under the penalties of perjury and falsification that I am indigent and that payment of the $25.00 filing fee would create a financial hardship for me. Plaintiff’s signature* Date *Under R.C. 2921.11,R. .C. 2929.11 and 2929.18 perjury is a felony of the third degree and punishable by imprisonment of one to five years and a fine up to $10,000.00 Under R.C. 2921.13 and R.C. 2929.21 falsification is a misdemeanor of the first degree and punishable by imprisonment of six months and a fine not more than $1,000.00. Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com