Ohio Civ.R. 20. — CIVIL FEE WAIVER AFFIDAVIT AND ORDER

IN ____________________________________________

_______________________________________________

CASE NO.

JUDGE

FINANCIAL DISCLOSURE / FEE- WAIVER AFFIDAVIT AND ORDER

Pursuant to R.C. 2323.311, the below-named Applicant requests that the Court determine that the Applicant is an indigent litigant and be granted a waiver of the prepayment of costs or fees in the above captioned matter. The Applicant submits the following information in support of said request.

))))))))

Plaintiff,

vs.

Defendant.

Personal Information Applicant’s First Name Applicant’s Last Name

Applicant’s Date of Birth Last 4 Digits of Applicant’s SSN

Applicant’s Address

Other Persons Living in Your Household First Name Last Name Is this person a child under 18?

Relationship (Spouse or Child)

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

Public Benefits I receive the following public benefits and my gross income, including the cash benefits marked below, does not exceed 187.5% of the federal poverty guidelines.

Place an “X” next to any benefits you receive.

Ohio Works First1: ___ SSI2: ___ Medicaid3: ___ Veterans Pension Benefit4: ___ SNAP / Food Stamps5: ___

Monthly Income I am NOT able to access my spouse’s income ☐

Applicant Spouse (If Living in Household) Total Monthly Income

Gross Monthly Employment Income, including Self-Employment Income (Before Taxes) $ $ $ Unemployment, Worker’s Compensation, Spousal Support (If Receiving) $ $ $ TOTAL MONTHLY INCOME $ $

Liquid Assets Type of Asset Estimated Value Cash on Hand $ Available Cash in Checking, Savings, Money Market Accounts $ Stocks, Bonds, CDs $ Other Liquid Assets $ Total Liquid Assets $

Monthly Expenses Column A Column B Type of Expense Amount Type of Expense Amount Rent / Mortgage / Property Tax / Insurance $

Insurance (Medical, Dental, Auto, etc.) $ Food / Paper Products/Cleaning Products/Toiletries $

Child or Spousal Support that You Pay $

Medical / Dental Expenses or Associated Costs of Caring for a Sick or Disabled Family Member $ Transportation / Gas $ Credit Card, Other Loans $ Phone $ Taxes Withheld or Owed $ Child Care $ Other (e.g. garnishments) $ Total Column A Expenses $ Total Column B Expenses $ TOTAL MONTHLY EXPENSES (Column A + Column B)

Utilities (Heat, Gas, Electric, Water / Sewer, Trash) $

I, ______________________________________, hereby certify that the information I have provided on

(Print Name) this financial disclosure form is true to the best of my knowledge and that I am unable to prepay the costs or fees in this case.

____________________________________

Signature NOTARY PUBLIC: Sworn to before me and signed in my presence this ______ day of _______________________, 20_____, in ___________________ County, Ohio.

____________________________________

Notary Public (Signature)

____________________________________

Notary Public (Printed)

My Commission expires:________________

If available, an individual duly authorized to administer this oath at the Clerk of Court’s Office will do so at no cost to the Applicant. ____________________________________________________________________________________________

ORDER

☐ Upon the request of the Applicant and the Court’s review, the Court finds that the Applicant IS an indigent litigant and GRANTS a waiver of the prepayment of costs or fees in this matter. Pursuant to R.C. 2323.311(B)(3), upon the filing of a civil action or proceeding and the affidavit of indigency under division (B)(1) of this section, the clerk of the court shall accept the action, motion, or proceeding for filing.

☐ Upon the request of the Applicant and the Court’s review, the Court finds that the Applicant is NOT an indigent litigant and DENIES a waiver of the prepayment of costs or fees in this matter. Applicant is granted thirty (30) days from the issuance of this Order to make the required advance deposit or security. Failure to do so within the time allotted may result in dismissal of the applicant’s filing.

IT IS SO ORDERED

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________________________ Judge / Magistrate

Date