1. society
2. social institution
3. divorce

j!How TO FILE AN ANSWER TO A DIVORCE COMPLAINT WITHOUT AN ATTORNEY
As you know, from the attached letter, our office will not be
able to represent you in Court in the divorce filed against you.
You
told
us
there
were
no
child(ren)
born
as
issue
(If you and spouse do have minor children,
marriage.
before you use this packet.)
to
your
call us
With our limited resources, we are
not able to represent everyone who asks for our help.
if you can afford, to hire an attorney to help you.
It is best,
If you cannot
afford an attorney, this packet can provide you with information on
how to answer
the divorce
complaint
so that you will
have an
opportunity to tell your side in Court. IT IS VERY IMPORTANT THAT
YOU ANSWER THE COMPLAINT AND THAT YOU ATTEND EVERY HEARING AND THAT
YOU KEEP THE COURT AND YOUR SPOUSE'S ATTORNEY AWARE OF YOUR CURRENT
ADDRESS. We will not be your attorney in this matter.
YOU MUST ANSWER THE COMPLAINT WITHIN 28 DAYS
OF THE DATE YOU WERE SERVED
The first page is usually the SUMMONS.
It demands that you
Answer the Complaint within 28 days after you are served with the
Summons.
YOU MUST FILE YOUR ANSWER WITHIN 28 DAYS AFTER YOU
RECEIVED THE SUMMONS AND COMPLAINT.
Immediately after the Summons should be the Divorce Complaint
against you.
Read the Complaint carefully.
If you do not answer
the Complaint in writing within 28 days after you receive it, the
Court may believe what the Complaint says is true and your spouse
1
IJ
could get a divorce from you and get everything they have asked for
from the Court.
hearing,
If you do not answer and do not go to the final
then you will not get your day in Court.
Again,
it is
very important that you keep the Court and your spouse's attorney
informed
regarding
your
current
address
so
you
will
receive
notification of all Court hearings.
I HOW
TO PREPARE YOUR WRITTEN ANSWER/
Preparing a written Answer to the Complaint is easy.
the Sample Answer attached to see how an Answer looks.
Look at
You should
type or neatly write your Answer.
Your answers tell the Court what you believe is wrong in the
Complaint and what you would like the Court to do for you in the
divorce.
Blank lines have been provided in the attached Answer
form for you to use (No. 6 and No. 7).
put where.
Look at page 8 for what to
Look at the sample Answer showing how an Answer might
look when it is completed.
Go through the Complaint paragraph by paragraph to see if the
Complaint says anything that you believe is wrong.
For example, if
the Complaint has the wrong marriage date, you should state in your
Answer the correct date of marriage.
Or if the Complaint says
there are no debts from the marriage and you do not believe this is
true, you should type or write in the blank lines of your Answer
that you there are debts from the marriage and list them.
2
Finally, you should also write or type in your Answer what you
would like the judge to do for you.
Below are some things you may
ask the judge to do for you:
•order your spouse to help support you including providing
health insurance
•divide up the marital property (including debts)
•order your spouse to pay some or all the marital debts
•order your spouse to give you a part of any pensions or
retirement benefits, if your spouse has a pension or
retirement benefits
•give you back your maiden name
At the end of Answer,
number legibly.
write your name,
address,
and phone
SIGN YOUR ANSWER.
Complete the Certificate of Service by filling in the name and
address of your spouse's lawyer (or your spouse's name and address
if your spouse if doing the divorce him/herself) .
PLEASE NOTE: Some courts may require other documents to be
filed with your Answer.
If other documents are required by your
court, those documents are included with this packet with a cover
sheet listing the additional documents required to be filed with
your Answer.
You should complete those documents and if they are
required to be notarized, you must sign them in front of a notary.
You will be copying, serving and filing those documents with your
Answer in the same way and at the same time as your Answer.
I HOW
TO SERVE AND TO FILE YOUR ANSWER and
3
I
ANY OTHER DOCUMENTS
After you have prepared and signed your Answer and any other
documents included, [SEE LIST ATTACHED "WHAT TO FILE"] you need to
immediately make two (2) photocopies of all documents.
handwrite
your
photocopies
against you.
to
copies.
the
That
same
attorney who
Although you do
day
signed
MAIL
the
one
(You cannot
set
Divorce
of
these
Complaint
not have to mai 1 the Answer by
certified mail, you may want to ask the post office to provide you
with a Certificate of Mailing, which proves you mailed the Answer
on the date it was mailed, to the person to whom it was addressed.
Within 3 days of mailing one copy of all documents to the
attorney who filed the complaint against you, you must take the
original of your Answer and your remaining photocopies to the clerk
of the common pleas court that served the papers on you.
Be sure
that you go to the Common Pleas Court where the Complaint was
filed.
Take the Complaint with you to the clerk's office and show
it to the clerk to confirm that you are in the right place. Then
give the clerk both your original Answer (and all other documents)
and your photocopies.
Ask the clerk to file-stamp the original(s)
and the copies and to give you a copy back of everything that you
filed.
The clerk will then keep the original(s), which will go into
the Judge's file so that the Judge can read it.
The file-stamped
photocopies should be returned to you by the clerk.
4
Keep your
file-stamped copies in a safe place because it is your proof that
you filed your Answer in the place and on the date shown in the
file stamp.
It is like a receipt.
IF THE CLERK REFUSES TO TAKE
YOUR ANSWER, PLEASE CONTACT US IMMEDIATELY.
AND THEN WHAT?
After you are done with all of this, the Judge will have your
Answer, the person who filed the complaint against you will have a
copy of your Answer, and you will have a copy of your Answer with
proof that you have filed the original with the Court.
Everyone
will know where you stand and what you want from the divorce. The
Court will then keep you updated on what happens in your case, and
the person who filed the complaint against you will know where to
send any additional papers that he or she may file with the Court.
You must keep the Court and the other side up-to-date on what
your current address is and what your telephone number is, if you
have a phone number.
This is so that the Court and the other side
can continue to communicate with you.
If you move and do not tell
the Court or the other side, they will not look for you. If any of
the information you gave the Court in your answer changes,
send
another letter with the new information to the Clerk with the case
number and parties' names and send a copy to the other side.
5
IMPORTANT! !
IF YOU ARE SENT ANY DOCUMENTS FROM THE COURT TO COMPLETE, YOU
MUST DO SO BY THE TIME SPECIFIED.
COURT
REQUESTS.
YOU MUST COOPERATE WITH ALL
IF YOU RECEIVE ANY DOCUMENT WITH A NOTICE OF
HEARING, YOU SHOULD GO TO THAT HEARING.
The Court may schedule your case for what is called a pretrial hearing.
This is an informal meeting with the Judge and the
people involved in the case to see what issues in the divorce you
and your spouse agree on and what issues you disagree on.
The
Judge will also decide how long the final hearing will take and
what issues need to be decided.
Eventually,
divorce hearing.
the Court will schedule your case for a
final
At that hearing you will have the opportunity to
present witnesses (including yourself) and other evidence (such as
copies of unpaid bills from the marriage or documents showing your
spouse has a pension)
about the statements in the complaint and
about what you want from the divorce.
After hearing evidence from
both sides and deciding what evidence is admissible and what is
not, the Judge will render a decision.
Sometimes, the Judge gives
his or her decision "from the bench" immediately after the hearing,
or he or she gives the decision later, after having an opportunity
to think about the case.
If, after you have followed all these steps, you learn that a
6
decision has been rendered against you and you were not notified of
the hearing and did not attend, please contact us immediately.
Or
if you believe the Court or your spouse acted improperly, give us
a call right away.
you acted
If the Court or the person who filed against
improperly and you were
significantly hurt by their
actions, we might be able to do something about that.
Good luck!
P: \Forms-Macros\Screening Manual Forms\32 (A) ( 3) Divorce Defense without children\Di vorce Answer Instructions. wpd
7
HOW TO FILL IN THE BLANKS
You need to fill in the numbered blanks.
1.
Blank 1
Put County divorce papers filed in.
2.
Blank 2a
Blank 2b
Put your spouse's name.
Your spouse's address.
3.
Blank 3
Put Case No.
4.
Blank 4
Put Judge's name.
5.
Blank 5a
Blank 5b
Put your name.
Put your correct address.
6.
Blank 6
Put why your disagree with divorce or any problems
you have.
7.
Blank 7
Put what you want the Court to do.
8.
Blank Sa
Blank 8b/c
Blank 8d
Sign your name.
Put your address.
Put your phone number.
9.
Blank 9
Put address of your spouse's lawyer.
10.
Blank 10
Put date mailed.
11.
Blank 11
Sign your name.
(get from Complaint)
8
(Get from Complaint.)
IN THE COURT OF COMMON PLEAS, -------1~---------------------COUNTY, OHIO
-2aPlaintiff's Name
CASE NO.
-2b-
JUDGE
-3-
-4-
Plaintiff's address
Plaintiff,
vs.
DEFENDANT'S ANSWER
-SaDefendant's Name
-5b-
Defendant's address
Defendant.
I, the Defendant, answers the Complaint as follows:
-6-
9
I ask the Court to:
-7-
I swear that the information contained in the foregoing Answer is true and
correct to the best of my information and belief.
-Sa( Sign your name)
Pro se
-Sb(Address)
-Be(City and State)
-Sd(Telephone Number)
CERTIFICATE OF SERVICE
A copy
of
this
document
was
served
attorney at the following address:
upon
Plaintiff
or
Plaintiff's
-9-
by ordinary U.S. Mail, postage pre-paid, this
-10-
day of
-10-
-11-
(Your signature)
P:\Forms-Macros\Screening Manual Forms\32(A) (3) Divorce Defense without children\Divorce Answer Instructions.wpd
11
I ask the Court to:
I vvan·b my husbcu110L 1-o pccv our .bi'/ls.
I swear that the information contained in the foregoing Answer is
true and correct to the best of my information and belief.
Pl2'
I
se
;G ;_IV.
i/Hl
Sh~e.e t
(Address)
>!}i:r- tocu11 Ol7lo
(CltY and State)
XXX'- XXk-,tzX X
(Telephone Number)
CERTIFICATE OF SERVICE
A copy of this document was served upon Plaintiff or upon
Plaintiff's attorney at the following address:
....::('~='>l...!_.l_!..:t:=::!c='·st.;..~_:__,-"6~t_':. ~.' i1..\.__TU.,c~,l::..::o0,:.:.';\._)-=-'_O__:_H,_______
L:..!..J
I
U.S. Mail, postage pre-paid, this
A:\Di\"orce How To\No Kids\blankanswer.wpd
by ordinary
rY
CASE NO.
, OHIO
qq-DR-OXX
Plaintiff's Name
1'2. E. MAIN ST.
JUDGE
'Yourz.
J'uo6 E
Plaintiff's address
'/0 UP- TtNIJ AJ 0 r-f
Plaintiff,
vs.
DEFENDANT'S ANSWER
Defendant's Name
Defendant's address
""/OU"K Tc ll1!J 0 li
Defendant.
I, the Defendant, answers the Complaint as follows:
·~
\Ne
t.E
IN THE COURT OF COMMON PLEAS, _____________________COUNTY, OHIO
CASE NO.
Plaintiff's Name
JUDGE
Plaintiff's address
Plaintiff,
vs.
DEFENDANT'S ANSWER
Defendant's Name
Defendant's address
Defendant.
I, the Defendant, answers the Complaint as follows:
I ask the Court to:
I swear that the information contained in the foregoing Answer is
true and correct to the best of my information and belief.
Pro se
(Address)
(City and State)
(Telephone Number)
CERTIFICATE OF SERVICE
A copy of this document was served upon Plaintiff or upon
Plaintiff's attorney at the following address:
by ordinary
U.S. Mail, postage pre-paid, this ___ day of
(Your signature)
P:\FomlS-Macros\Screening Manual Fonns\32(A)(3) Divorce Defense without children\Blank Answer fonn.wpd
FINANCIAL AFFIDAVIT/MOTION FOR TEMPORARY ORDERS
HOCKING COUNTY COMMON PLEAS COURT
DOMESTIC RELATIONS DNISION
INSTRUCTIONS
This form is required in the Domestic Relations Court. If you do not fill out this form,
you will not be permitted to file. Therefore, it is important that you read this form carefully and
fill out all sections to the best of your ability.
Page 1
1.
You should fill out this form before you go to the courthouse to file it. The court will not
help you in completing this form. Make sure this form is typewritten or printed neatly.
At the top of this form you will need to fill in the names of the Plaintiff and Defendant
(the two spouses). If you are filing the divorce, then you are the Plaintiff and your spouse
is the Defendant.
2.
You are the Affiant. Write your name on this blank.
3.
Part A: Check off the box(es) that apply to the type of relief you are requesting the Court
to grant. For example, if you are requesting child support, you would check the box
"Child Support" and also the box marked residential parent allocation stating that you
want custody of the child/children. You could also check the boxes for spousal support,
debt allocation and legal fees if you want the court to consider ordering these on your
behalf. Should you be seeking custody of the child/children then you should file with
this a sworn statement (Affidavit) listing the reasons that the court should grant you
custody of the children. (See Ex. 2(A)) It should be noted that you will need to fill in the
appropriate blanks listing the Plaintif£'Defendant, County and Case No. You will also
need to print your name on the line before the words "being duly cautioned and sworn".
4.
Part B: Notice of Hearing. Leave this part blank- the Clerk will fill this in.
5.
Part C: Case Information. You need to fill in your side of the table (whether you are
Husband or Wife) with your name, street address, city/state/zip, telephone, Social
Security number, date of birth, and age. You can fill in the other side if you want and
know the information, but it is not necessary.
6.
Under the colored line in the table, you must fill in all the sections. You will need to fill
in your date married, when separated (if applicable), number of children, children's ages,
with whom children live, number of dependents, children's address, whether your home
is rented or owned, who occupies your home, and number of dependent children from
previous marriage for Husband and Wife.
1.
Part D: Annual Income (Again, fill in your side of the table. However, if you know your
spouse's approximate income or employer you should list it under their side of the
colunm.): Fill in your employer (or other source ofincome)'s name, the street address,
city/state/zip, and telephone number. However, if you have information in regards to
your spouse's income and employer, you should fill in the appropriate blanks. Then fill
in as much as you can of the rest of the table. Write in "0" if you do not receive gross
income from any of the sources. Be sure to fill in the total gross annual income where
requested. You will also need to attach verification in the form of a current pay stub, W2, tax return, etc. Please note this is annual income so it must be what you make in gross
income in a year. Further, if your only source of income is public benefits (OWF, SS,
DA etc.) you should list it in this section.
2.
Deductions From Income: You can usually find this infonnation on your pay stub or W-2
form. Be sure to fill in the total annual deductions.
3.
Subtract your total annual deductions from your total gross annual income to get your
total net annual income and fill it in the bottom part of the table.
Page 3
1.
PartE: Financial Disclosure. Here is where you will list any accounts at a bank, savings
and loan, credit union, or other financial institution. You must list any of the following
types of accounts: checking, certificate of deposit (CD), investment, savings, individual
retirement (IRA), stock options, etc. You must list all accounts in which you have an
interest, even if your name is not on the account. Therefore you must list any accounts
belonging to your children. You must list any amounts of cash over $250. You must list
accounts even if the balance is $0.
Fill in the name of the financial institution, its address, the account number, the name on
the account, and the balance.
2.
Part F: Dependent Information. Here you list any biological or adoptive minor child not
the subject of this action that live with you (again, only fill in your side of the chart).
This would include children from a previous marriage or relationship, for example. If
your spouse has children from a previous marriage or relationship, do not include them.
You may include your own children from a previous marriage or relationship.
Page4
Part G: Expenses
You only need to fill out your side of the table. You must fill in the amount you actually pay
each month for these expenses.
Page 5
Part H: Debts
You must list all debts owed by each party. In the "debtor" colunm, you must note whether the
debt is the husband's debt, the wife's debt, or a joint debt. Show this by marking an H, W, or J
in that column. In the next column, write who has possession or use of the item; for example,
who is driving the car on which the debt is owed. You may estimate the principal to the best of
your knowledge. Most importantly, you must fill in what you pay per month on this debt in the
final column.
Page6
1.
Part I: Group Health Insurance For Minor Children. You do not need to complete this
section if minor children are not involved in your action. However, if they are, you must.
Fill in your information on your side of the table. If you get health insurance through a
social services program, be sure to note that. Do not forget to fill in the summary of the
benefits of your plan in the appropriate section.
2.
You will need to sign where it says "Affiant" but you may only sign this form in the
presence of a Notary Public. One place you might try to find a Notary Public is at your
local bank.
GOOD LUCK!
P:\Forms-Macros\Pro se\Hocking\Common Pleas\Financial Affidavit lnstructions.wpd
IN THE COURT OF COMMON PLEAS OF HOCKING COUNTY, OHIO
DOMESTIC RELATIONS DIVISION
PI aintiff!P eti tio n er
-vs-/-and-
Case No.: - - - - - - - -
Defendant/Petitioner
FINANCIAL AFFIDAVIT/MOTION
FOR TEMPORARY ORDERS/AFFIDAVIT
OFHEALTHINSURANCECOVERAGE
- - - - - - - - ' Affiant(s), being duly sworn, say(s):
PART A- TEMPORARY RELIEF REQUESTED
I am requesting the following relief:
0
Financial Disclosure Only
0
Spousal Support
0
Residential Parent Allocation
0
Debt Allocation
0
Companionship Only
0
0
Child Support
0
Legal Fees and Expenses
(Amount Requested
Other (Please Specify)
PART B - NOTICE OF HEARING
on the
This matter shall come on for non-oral hearing on affidavits only (parties and counsel need not appear)
day of
, ___ at
.m.
PART C- CASE INFORMATION
Husband
Wife
Full Name
Street Address
City/State/Zip
Telephone
Social Security No.
Date of Birth/Age
Number of Children
S~parated
Date Married
When
Children's Ages
With Whom Children Live
Children's Address
Home Rented or Owned?
Occupied By
--
1
Number of Dependents
Number of Dependent Children by
Previous Marriage- H
w
PARTD-ANNUALINCOME
Wife
Husband
Employer/Source of Income
Street Address
City/State/Zip
Telephone
•
$
$
Gross annual overtime or bonuses
$
$
Gross annual unemployment benefits
$
$
com~nsation
$
$
Gross annual interest or dividends
$
$
Child support received for other children
$
$
Spousal support received from_prior marriae:e
$
$
Other: (eg. pensions, annuities, etc.)
$
$
TOTAL GROSS ANNUAL INCOME:
$
$
Gross annual wages or self employment income
(excludinl! overtime and bonuses).
Gross annual worker's
*Attach Verification- Current Pay Stub, W-2's, Tax Return, Etc.
Deductions from Income
Income Tax Actually PaidJ!'ederai/State!Local)
$
$
F.I.C.A.
$
$
MandatQ!Y_ Retirement Plan
$
$
Union Dues
$
$
Health Insurance Coverage
$
$
Child Support Withheld From Income
$
$
Spousal Support Withheld From Income
$
$
TOTAL ANNUAL DEDUCTIONS:
$
$
TOTAL NET ANNUAL INCOME:
$
$
PARTE- FINANCIAL DISCLOSURE
LIST ALL CASH AND FUNDS ON DEPOSIT IN ANY AND ALL ACCOUNTS IN ANY BANK,
SAVINGS AND LOAN, CREDIT UNION OR OTHER FINANCIAL INSTITUTION. ACCOUNT MAY
INCLUDE ONE OR MORE OF THE FOLLOWING: CHECKING, CERTIFICATE OF DEPOSIT,
INVESTMENT, SAVINGS, INDIVIDUAL RETIREMENT, STOCK OPTION, ETC. NOTE- YOU
ARE REQUIRED TO DISCLOSE ALL FUNDS IN WHICH YOU HAVE AN INTEREST
REGARDLESS OF THE NAME IN WHICH THESE FUNDS ARE HELD. INCLUDE CASH OVER
$250.00.
2
N arne of Financial
Institution
Address
Account
Number
Name On
Account
Balance
PART F- DEPENDENT INFORMATION
LIST EACH BIOLOGICAL OR ADOPTIVE MINOR CHILD, NOT THE SUBJECT OF THIS ACTION, LIVING WITH EITHER
PARTY. (DO NOT INCLUDE THE CHILDfREN) INVOLVED IN THIS ACTION. DO NOT INCLUDE STEP-CHILDREN.)
Husband's Household
Child's Name
Wife's Household
Date of Birth
Child's Name
3
Date of Birth
PART G - EXPENSES
STATE YOUR ACTUAL EXPENSES PER MONTH'
Husband
Wife
$
s
a. Gas
$
$
b. Electric
$
$
c. Phone
$
$
d. Other (Identify)
$
$
3. Insurance
$
$
a. Auto
$
$
b. Life
$
$
c. Health (Not withheld from income)
$
$
4. Uninsured Medical/Dental
$
$
5. Clothing
$
$
6. Groceries & Household Supplies
$
$
a. Fuel
$
$
b. Maintenance & Repairs
$
$
8. Work-Related Child Care (~ttach verification)
$
$
9. Child Support Paid For Other Child(ren)
$
$
10. Spousal Support Paid For Ex-Spouse
$
$
11. Other (Please identify)
$
$
1. Rent (Not to include mortgage payments)
2. Utilities
7. Transportation
(Not withheld from income)
4
PART H- DEBTS
LIST ALL DEBTS OWED BY EACH PARTY, WHETHER ALLEGED TO BE MARITAL OR
SEPARATE DEBT. DO NOT INCLUDE ANYTHING LISTED IN PART GAS EXPENSES.
Secured Creditors
Debtor
HWJ
Person in
Possession, Use
or Occupancy
Principal
Monthly
Installment
Principal
Monthly
Installment
Mortgage
2nd
Mortga~e
Auto
Auto
Other
Unsecured Creditors
Debtor
HWJ
5
PART I- GROUP HEALTH INSURANCE FOR MINOR CHILDREN
INSTRUCTIONS: IF MINOR CHILDREN ARE INVOLVED IN THIS ACTION, ANSWER THE
FOLLOWING QUESTIONS ABOUT THE AVAILABILITY, COST, AND COVERAGE OF GROUP
HEALTH INSURANCE FOR THE MINOR CHILDREN. IF MINOR CHILDREN ARE NOT INVOLVED
IN THIS ACTION, DO NOT COMPLETE PART I.
Husband
Wife
AVAILABLE THROUGH EMPLOYER (Yes or No)
AVAILABLE THROUGH NON-EMPLOYER (Yes or No)
NAME AND ADDRESS OF INSURANCE COMPANY
GROUP POLICY NUMBER
COST TO YOU OR THE OTHER PARTY PER YEAR:
(For children only)
$
$
Summarize the benefits of each plan (ie. DEDUCTIBLES, CO-PAYMENTS, HMO, COMPREHENSIVE, MAJOR MEDICAL,
DENTAL OPTICAL ETC. .. ).
Husband's Policy:
Wife's Policy:
Affiant
Sworn to and subscribed before me this _ _ day of _ _ _ _ _ _, _ _.
Notary Public
Affiant
Sworn to and subscribed before me this _ _ day of _ _ _ _ _ _. _ _
Notary Public
P:\FomlS-Macros\Pro se\Hocking\Common Pleas\Financial Affidavit.wpd
6
TYPE OR PRINT ONLY
INSTRUCTIONS FOR POVERTY AFFIDAVIT
I.
Fill in the name of the county where the action is.
2.
Fill in the name of the parties to the action.
3.
Leave blank the case number line unless you know the case number.
4.
Fill in your name.
5.
Sign your name in front of a notary if the affidavit is
correct.
MAKE 2 COPIES AND TAKE WITH YOUR PAPERS TO COURT
IN THE COURT OF COMMON PLEAS
_ _ _ _ _ COUNTY, OHIO
CASE NO. _ _ __
vs.
AFFIDAVIT OF INABILITY TO
PREPAY OR GNE SECURITY
FOR COSTS.
Sec. 2323.31 Revised Code
STATE OF OHIO
)
)
_ _ _ _ COUNTY)
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. 2323.31 of the Revised Code.
In support of this request, I submit answers to the following questions:
1. What is your age? _ _ years
2. 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 name and address of your employer.
5. What did you earn during the past year?
6. What are your parent's names and ages?
7. Do you own any real estate? ___ If so, give its value_ _ _ _ _ _ _ _ _ ,
Is it mortgaged?___ If so, give the amount of the mortgage. _ _ _ _ __
8. Do you own an automobile? ___ If so, what is the value? _ _ _ _ _ __
9. What other things do you o w n ? - - - - - - - - - - - - - - - - What debts are against it?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
12. Are you receiving public assistance? ___ If so, what kind? _ _ _ _ _ __
How much? _ _ _ _ _ __
Signature
STATE OF OHIO
)
)
ss
_ _ _ _ _ COUNTY)
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
IN THE COURT OF COMMON PLEAS
_ _ _ _ _ COUNTY, OHIO
CASE NO. _ _ _ __
vs.
JUDGMENT ENTRY
Upon Affidavit of the Petitioner and for good cause shown, it is hereby ordered that the
Petitioner be allowed to proceed without prepayment of costs in this matter.
IT IS SO ORDERED.
JUDGE _ _ _ _ _ _ _ _ ___
FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY
Ill MONTHLY INCOME/EMPLOYMENT INFORMATION
Type of Income
Employment {Gross)
Self
Household Members
Spouse
Total
Unemployment
Worker's Camp.
Pension
Social Security
Child Support
ADC
Disability
other
Employer's Name (for all household members)
Address
SUBTOTAL A
Phone
(
IV ALLOWABLE MONTHLY EXPENSES
Amount
Type of Expense
V. TOTAL INCOME
SUBTOTAL A
-SUBTOTAL B
i
of Caring for Inform Family
Members
GRAND TOTAL C
D
)
VII MONTHLY LIABILITIES/OTHER EXPENSES
Type of Liability
Rent/Mortgage
Food
Electric
Gas
Fuel
Telephone
Cable
Water/Sewer/Trash
Credit Cards
Loans
Taxes Owed
Other
VII GRAND TOTALS
Amount
Grand Total C
Total Monthly Income
Grand Total D
Total Assets
Grand Total E
Total Monthly Liabilities
and Other Expenses
GRAND TOTAL E
IX. AFFIDAVIT OF INDIGENCY
I,
being duly sworn, say:
1.
2.
3.
4.
5.
I am financially unable to retain private counsel without substantial hardship to me or my family.
I understand that I must inform my attorney if my financial situation should change before the
disposition of my case.
I understand that it if is determined by the county, or by the Court, that legal representation was
provided for me to which I was not entitled, I 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.
I understand that I am subject to criminal charges for providing false financial information in
connections with the above application for legal representation pursuant to Ohio Revised Code
Section 120.05 and 291.13(A)(13), (0)(4).
I hereby certify that the information I have provided on this financial disclosure form is true to the
best of my knowledge.
Client Signature
Date
Notary Public:
Subscribed and duly sworn before me according to law, by the above named applicant this _ _ _ day of
_ _ _ _ _ _ _ _ _ _ at
, County of
and State of _ _ _ _ __
Notary Signature
X. JUDGE/ATTORNEY CERTIFICATION
I hereby certify the above-noted client is unable to fill out this financial disclosure form and/or is
unable to sign the above affidavit. I have determined that the applicant meets the criteria for receiving court
appointed counsel.
Judge/Attorney Signature
Date