Financial Disclosure/affidavit Of Indigency - Divulgacion Financiera/declaracion Jurada De Indigencia Page 3
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3IX. AFFIDAVIT OF INDIGENCY / DECLARACIÓN JURADA DE INDIGENCIA
I, _______________________________________________________(affiant) being duly sworn, say :
Yo, ______________________________________________________ (declarante), habiendo sido debidamente jurado, declaro qué:
1.
I am financially unable to retain private counsel without substantial hardship to me or my family.
Yo no tengo los medios económicos para poder contratar un abogado para representarme sin que resulte en privacion financiera considerable para mí o mi
familia.
2.
I understand that I must inform the public defender or appointed attorney if my financial situation should change before the disposition of the case(s) for
which representation is being provided.
Yo entiendo que debo informar al defensor publico o al abogado nombrado si cambian mis condiciones financieras antes de la disposición del caso en el
cual estoy siendo representado(a).
3.
I understand that if it is determined by the county, or by the Court, that legal representation should not have been provided, 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.
Yo entiendo que si determina el Condado o el tribunal que no es necesario proporcionar la representación legal, es posible que yo tenga que
reembolsar los costos de la representación proporcionada al Condado. Cualquier esfuerzo del condado para recaudar costos legales
relacionado con su representación en estas causas tendran que ser tomado antes de los dos años despues de la ultima fecha de su
representación.
4.
I understand that I am subject to criminal charges for providing false financial information in connection with the above application for legal
representation pursuant to Ohio Revised Code Sections 120.05 and 2921.13.
Entiendo que estoy sujeto a cargos criminales por proveer informacion falsa en conexión con esta aplicación para representación legal
conforme al Código Revisado de Ohio, Secciones 120.05 y 2921.13.
5.
I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge.
Certifico que la información que he provisto en este documento de declaración financiera es cierta de acuerdo a mi mejor conocimiento.
/
/
Affiant’s Signature
Firma del/de la declarante
Date
Fecha
Notary Public/Individual duly authorized to administer oath:
Notario público/Individúo debidamente autorizada para administrar juramento:
Subscribed and duly sworn before me according to law, by the above named applicant this ______ day of _______________________, _______,
at _______________________, County of ___________________________ and State of _________________.
Firmado y debidamente juramentado ante mí según ley, por el/la solicitante indicado/a arriba el ______ de ___________ del 20_____, en
__________________, en el Condado de _______________ y el Estado de _______________.
__________________________________________________
__________________________________________________________
Signature of person authorized to administer oath
Title / Título
Firma de la persona autorizada para administrar juramento
X. INTERPRETER’S CERTIFICATION-CERTIFICACIÓN POR EL/LA INTÉRPRETE
Affidavit of Interpreter / Declaración Jurada dél Intérprete
I ________________________________________ do swear under the penalty of perjury that I am fluent in Spanish; I have explained to the
(Interpreter)
applicant that the information he/she supplies is given under oath and that providing false information on this form may subject applicant to
criminal charges and possible incarceration and that the applicant has sworn that the information provided is the truth.
Yo ______________________________________ juro bajo la penalidad de perjurio que domino el español; Le he explicado a
(Intérprete)
el/la solicitante que toda la información que provee es dada bajo juramento, que si provee falsa información en este formulario puede estar
sujeto(a) a cargos criminales, posible encarcelación y que el/la solicitante ha jurado que la información provista es cierta.
__________________________________________________________
Interpreter / Intérprete
Subscribed and duly sworn before me, by the interpreter this ______ day of _______________________, _______,
at _______________________, County of ___________________________ and State of _________________.
Firmado y jurado ante mí, por el/la intérprete, el ______ de ___________ del 20_____, en __________________, en el Condado de
_______________ y el Estado de _______________.
__________________________________________________
__________________________________________________________
Signature of person administering oath
Title / Título
Firma de la persona administrando juramento
XI. JUDGE CERTIFICATION
I hereby certify that above-noted applicant is unable to fill out and/or sign this financial disclosure/ affidavit for the following reason:
________________________________________________________________________________________________________________.
I have determined that the applicant meets the criteria for receiving court appointed counsel.
Judge’s Signature
Date
OPD-206R/S Revised June 19, 2008
#241653
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