Form Opd-206r - Financial Disclosure / Affidavit Of Indigency
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2FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY
($25.00 application fee may be assessed—see notice on reverse side)
I. PERSONAL INFORMATION
D.O.B.
Person Represented’s Name (if juvenile)
D.O.B.
Applicant’s Name
Mailing Address
City
State
Zip Code
Case No.
Phone
Cell Phone
(
)
(
)
II. OTHER PERSONS LIVING IN HOUSEHOLD
Name
D.O.B.
Relationship
Name
D.O.B.
Relationship
1)
3)
2)
4)
III. PRESUMPTIVE ELIGIBILITY
The appointment of counsel is presumed if the person represented meets any of the qualifications below. Please place an ‘X’
Ohio Works First / TANF: ____ SSI: ____ SSD: ____ Medicaid: ____ Poverty Related Veterans’ Benefits: ____ Food Stamps: ____
Refugee Settlement Benefits: ____ Incarcerated in state penitentiary: ____ Committed to a Public Mental Health Facility: ____
Other (please describe): ____________________________________________________________
Juvenile: ____
(if juvenile, please continue at Section VIII)
IV. INCOME AND EMPLOYER
Spouse
Applicant
Total Income
(Do not include spouse’s income if spouse is alleged victim)
Gross Monthly Employment Income
Unemployment, Worker’s Compensation, Child
Support, Other Types of Income
TOTAL INCOME
$
Employer’s Name:______________________________________________________ Phone Number: ______________________________
Employer’s Address: ________________________________________________________________________________________________
V. LIQUID ASSETS
Type of Asset
Estimated Value
$
Checking, Savings, Money Market Accounts
$
Stocks, Bonds, CDs
$
Other Liquid Assets or Cash on Hand
$
Total Liquid Assets
VI. MONTHLY EXPENSES
Type of Expense
Amount
Type of Expense
Amount
Child Support Paid Out
Telephone
Child Care (if working only)
Transportation / Fuel
Insurance (medical, dental, auto, etc.)
Taxes Withheld or Owed
Medical / Dental Expenses or Associated Costs of
Credit Card, Other Loans
Caring for Infirm Family Member
Rent / Mortgage
Utilities (Gas, Electric, Water / Sewer, Trash)
Food
Other (Specify)
EXPENSES
$
EXPENSES
$
VII. DETERMINATION OF INDIGENCY
If applicant’s Total Income in Section IV is at or below 187.5% of the Federal Poverty Guidelines, counsel must be appointed.
For applicants whose Total Income in Section IV is above 125% of the Federal Poverty Guidelines, see recoupment notice in Section XI.
If applicant’s Liquid Assets in Section V exceed figures provided in OAC 120-1-03, appointment of counsel may be denied if applicant can employ counsel
using those liquid assets.
If applicant’s Total Income falls above 187.5% of Federal Poverty Guidelines, but applicant is financially unable to employ counsel after paying monthly
expenses in Section VI, counsel must be appointed.
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