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Get Affidavit Of Indigency

HAMILTON COUNTY MUNICIPAL COURT STATE OF OHIO Plaintiff CASE NO. -vs- AFFIDAVIT OF INDIGENCY Defendant After being duly cautioned and sworn I hereby state the following information is true to the best of my knowledge and belief. I understand I am subject to criminal charges for providing false information. I. II. INCOME Net Monthly Pay 1. Employer yrs. mos. Position Spouse s employer 2. Alimony/child support received 3. Public benefits received ADC SS SSI WC etc* 4. Other income pension interest etc* TOTAL INCOME ASSETS 1. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Other property Y/N MAJOR DEBTS Monthly Payments IV. FAMILY COMPOSITION 1. Number of persons you are required to support 2. Ages of such persons 3. Their relationship to you spouse child parent etc* I further state I am indigent at this time unable to pay the expungement application fee in the within matter and hereby request an indigency hearing before the Court. II. INCOME Net Monthly Pay 1. Employer yrs. mos. Position Spouse s employer 2. Alimony/child support received 3. Public benefits received ADC SS SSI WC etc* 4. Other income pension interest etc* TOTAL INCOME ASSETS 1. Public benefits received ADC SS SSI WC etc* 4. Other income pension interest etc* TOTAL INCOME ASSETS 1. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Other property Y/N MAJOR DEBTS Monthly Payments IV. FAMILY COMPOSITION 1. Number of persons you are required to support 2. Other property Y/N MAJOR DEBTS Monthly Payments IV. FAMILY COMPOSITION 1. Number of persons you are required to support 2. Ages of such persons 3. Their relationship to you spouse child parent etc* I further state I am indigent at this time unable to pay the expungement application fee in the within matter and hereby request an indigency hearing before the Court. II. INCOME Net Monthly Pay 1. Employer yrs. mos. Position Spouse s employer 2. Alimony/child support received 3. Public benefits received ADC SS SSI WC etc* 4. Other income pension interest etc* TOTAL INCOME ASSETS 1. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Public benefits received ADC SS SSI WC etc* 4. Other income pension interest etc* TOTAL INCOME ASSETS 1. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Other property Y/N MAJOR DEBTS Monthly Payments IV. FAMILY COMPOSITION 1. Number of persons you are required to support 2. Cash on hand Cash in bank Cash at home TOTAL CASH 2. Own motor vehicle Y/N Make Year Value 3. Own house Y/N How long 4. Other property Y/N MAJOR DEBTS Monthly Payments IV. FAMILY COMPOSITION 1. Number of persons you are required to support 2. Ages of such persons 3. Their relationship to you spouse child parent etc* I further state I am indigent at this time unable to pay the expungement application fee in the within matter and hereby request an indigency hearing before the Court..

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