Ohio Indigency Affidavit Form
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1
2INDIGENCY AFFIDAVIT
I. PERSONAL INFORMATION
Name/Applicant
Party Represented (if applicant, enter “same”)
D.O.B.
Mailing Address
City
State
ZIP
Case No.
Phone
Message Phone (within 48 hrs)
II. OTHER PERSONS LIVING IN HOUSEHOLD
Name
D.O.B.
Relationship
Name
D.O.B.
Relationship
1)
3)
2)
4)
III. MONTHLY INCOME/EMPLOYMENT INFORMATION
Type of Income
Employment (Gross)
Unemployment
Worker’s Comp.
Pension/Social Security
Child Support
Works First/TANF
Disability
Other
Employer’s Name (for all household members)
A. TOTAL INCOME
$
Employer’s Address
Phone
IV. ALLOWABLE EXPENSES
V. TOTAL INCOME
Type of Expense
Amount
Total Income- Allowable Expenses= Adjusted Total
Child Support Paid Out
Income
Child Care (if working only)
Transportation for Work
A. TOTAL INCOME
$
Insurance
-
B. EXPENSES
$
Medical/Dental
C. ADJUSTED TOTAL
INCOME
$
Medical & Associated Costs
Of Caring for Infirm Family
Members
B. EXPENSES
$
VI. ASSET INFORMATION
Type of Asset
Describe/Length of Ownership/Make, Model, Year
Estimated
(where applicable)
Value
Price: $
Date Purchased:
Amt. Owed: $
Real Estate/Home
Stocks/Bonds/CD’s
Automobiles
Trucks/Boats/Motorcycles
Other Valuable Property
Cash on Hand
Money Owed to Applicant
Other
Checking Acct. (Bank/Acct. #)
Savings/MM Acct. (Bank/Acct. #)
D. TOTAL ASSETS
$
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