This is an automatically generated accessible text version of the document. The original PDF is available above.

CIVILFEEWAIVERAFFIDAVITANDORDER IN . __ ) CASENO. ) Plaintiff, ) runGE ) vs. ) ) FINANCIALDISCLOSUREIFEE- ) WAIVERAFFIDAVIT Defendant. ) ANDORDER PursuanttoR.C.2323.311,thebelow-namedApplicantrequeststhattheCourtdeterminethattheApplicant isanindigentlitigantandbegrantedawaiveroftheprepaymentofcostsorfeesintheabovecaptioned matter.TheApplicantsubmitsthefollowinginformationinsupportofsaidrequest. PI.'rsonallnformation Applicant'sFirstName Applicant'sLastName Applicant'sDateofBirth Last4DigitsofApplicant'sSSN Applicant'sAddress OtherPersonsLiviru;inYourHousehold FirstName LastName IsthispersonachildRelationship(SpouseorChild) under18? DYes DNo DYes DNo DYes DNo PublicBenefits Ireceivethefollowingpublicbenefitsandmygrossincome,includingthecashbenefitsmarkedbelow,doesnot exceed187.5%ofthefederalpovertyguidelines. OhioWorksFirst': VeteransPensionBenefit":SNAP/FoodStamps":__ Placean"X"nexttoanybenefitsyoureceive. MonthlyIncome ~pPlicant ISpouse(IfLivingI linHousehold) TotalMonthlyIncome IamNOTabletoaccessmyspouse'sincomeD

GrossMonthlyEmploymentIncome, includingSelf-EmploymentIncome efore $ $ $ I, ,herebycertifythattheinformationIhaveprovidedon (PrintName) thisfinancialdisclosureformistruetothebestofmyknowledgeandthatIamunabletoprepaythecosts orfeesinthiscase. Signature NOTARYPUBLIC: Sworntobeforemeandsignedinmypresencethis dayof ,20__, III County,Ohio. NotaryPublic(Signature) NotaryPublic(Printed) MyCommissionexpires: _ Ifavailable,anindividualdulyauthorizedtoadministerthisoathattheClerkofCourt'sOfficewilldoso atnocosttotheApplicant.

ORDER DUpontherequestoftheApplicantandtheCourt'sreview,theCourtfindsthattheApplicantISan indigentlitigantandGRANTSawaiveroftheprepaymentofcostsorfeesinthismatter.Pursuant toR.C.2323.3II(B)(3),uponthefilingofacivilactionorproceedingandtheaffidavitofindigency underdivision(B)(I)ofthissection,theclerkofthecourtshallaccepttheaction,motion,or proceedingforfiling. . DUpontherequestoftheApplicantandtheCourt'sreview,theCourtfindsthattheApplicantisNOT anindigentlitigantandDENIESawaiveroftheprepaymentofcostsorfeesinthismatter. Applicantisgrantedthirty(30)daysfromtheissuanceofthisOrdertomaketherequiredadvance depositorsecurity.Failuretodosowithinthetimeallottedmayresultindismissaloftheapplicant's filing. ITISSOORDERED Judge/Magistrate [Effective:April15,2020;amendedeffect~veApril15,2022.] Date

ArPENDIX ~2022FEDERALPOVERTYLIMIT(FPL) T Personsin 100%Poverty 187.5%Poverty family/household 100%Poverty MonthlyGross187.5%PovertyMonthlyGross Income Income !$1,063.33 $23,925 $1,993.74 1 $12,16013,590 1,132.50 25,481.25 22123.44 $1,436.61 $32,325 $1,€i93.75 2 $1+,24018,310 I1,525.83 34,331.25 22860.94 $40,125 $3,393.75 $.J.,&+G1,919.17 3 $21,12023,030 43,181.25 32598.44 I$2,183.33 $49,125 $4,093.75 4 $26,20027,750 2,312.50 52,031.25 42335.94 $2,556.61 $51,525 $4,793.75 5 $30,68032,470 i 2,705.83 60,881.25 52073.44 $65,925 $5,493.75 $~3,099.l7 6 $35,16037,190 69,731.25 52810.94 $3,303.33 $14,325 $€i,193.75 , 7 $39,64041,910 3,492.50 78,581.25 62548.44 $3,616.61 $82,125 $€i,893.75 8 $44,12046,630 3,885.83 87,431.25 72285.94 I R.C.2323.311(B) (4)Ajudgeormagistrateofthecourtshallreviewtheaffidavitofindigencyasfiledpursuanttodivision(B)(2)ofthis sectionandshallapproveordenytheapplicant'sapplicationtoqualifyasanindigentlitigant.Thejudgeormagistrateshall approvetheapplicationiftheapplicant'sgrossincomedoesnotexceedonehundredeighty-sevenandfive-tenthspercent ofthefederalpovertyguidelinesasdeterminedbytheUnitedStatesdepartmentofhealthandhumanservicesforthestate ofOhioandtheapplicant'smonthlyexpensesareequalto'Ilrinexcessoftheapplicant'sliquidassetsasspecifiedin division(C)(2)ofsection120-1-03oftheAdministrative<tode,asamended,orasubstantiallysimilarprovision.Ifthe applicationisapproved,theclerkshallwaivetheadvancedepositorsecurityandthecourtshallproceedwiththecivil actionorproceeding.Iftheapplicationisdenied,theclerkshallretainthefilingoftheactionorproceeding,andthecourt shallissueanordergrantingtheapplicantwhoseapplicationisdeniedthirtydaystomaketherequiredadvancedepositor security,priortoanydismissalorotheractiononthefiling!ofthecivilactionorproceeding. (6)Nothinginthissectionshallpreventacourtfromapprovingoraffirminganapplicationtoqualifyasanindigentlitigant foranapplicantwhosegrossincomeexceedsonehundredeighty-sevenandfive-tenthspercentofthefederalpoverty guidelinesasdeterminedbytheUnitedStatesdepartmentdfhealthandhumanservicesforthestateofOhio,orwhoseliquid assetsequalorexceedtheapplicant'smonthlyexpensesasspecifiedindivision(C)(2)ofsection120-1-03ofthe AdministrativeCode,asamended,orasubstantiallysimilarprovision. 'OhioWorksFirstIncomeLimit:50%FPL(R.C.5107.l0(D)(l)(a)) 2SSIIncomeLimit:cannothavecountableincomethatexceedstheFederalBenefitRate(FBR).2019FBR:$771 monthlyforsingledisabledindividual;$1157monthlyfordisabledcouple(20CFR416.1100)

3MedicaidIncomeLimit: ModifiedAdjustedGrossIncome(MAGI):138%FPL«~AC5160:1-4-01;42USC1396a(a)(10)(A)(i)(VIII)) Aged,BlindorDisabled:$791forsingleperson;$1177fordisabledcouple "VeteransPensionBenefitIncomeLimit:$13,535annually/$1,127monthlyforasingleperson;$17,724annually/ $1,477monthlyforaveteranwithonedependent 5Supp1emental NutritionAssistanceProgram(SNAP)InfomeLimit:130%FPLforassistancegroupswith nondisabledinonelderlymember;165%FPLforelderlyanddisabledassistancegroups(OAC5101:4-4-11;Food AssistanceChangeTransmittalNo.61)

2023PovertyGuidelines:48ContiguousStates(allstatesexceptAlaskaandHawaii) PerYear Household! FamilySize 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Household! FamilySize 1 2 3 4 5 6 7 8 9 10 11 12 13 14 25% 50% 75% 100% 125% 130% 133% 135% 138% 150% 175% 180% 185% 200% $3,645 $4,930 $6,215 $7,500 $8,785 $10,070 $11,355 $12,640 $13,925 $15,210 $16,495 $17,780 $19,065 $20,350 225% $7,290 $9,860 $12,430 $15,000 $17,570 $20,140 $22,710 $25,280 $27,850 $30,420 $32,990 $35,560 $38,130 $40,700 250% $10,935 $14,790 $18,645 $22,500 $26,355 $30,210 $34,065 $37,920 $41,775 $45,630 $49,485 $53,340 $57,195 $61,050 275% $14,580 $19,720 $24,860 $30,000 $35,140 $40,280 $45,420 $50,560 $55,700 $60,840 $65,980 $71,120 $76,260 $81,400 300% $18,225 $24,650 $31,075 $37,500 $43,925 $50,350 $56,775 $63,200 $69,625 $76,050 $82,475 $88,900 $95,325 $101,750 325% $18,954$19,391 $25,636$26,228 $32,318$33,064 $39,000$39,900 $45,682$46,736 $52,364$53,572 $59,046$60,409 $65,728$67,245 $72,410$74,081 $79,092$80,917 $85,774$87,753 $92,456$94,590 $99,138$101,426 $105,820$108,262 350% 375% $19,683 $26,622 $33,561 $40,500 $47,439 $54,378 $61,317 $68,256 $75,195 $82,134 $89,073 $96,012 $102,951 $109,890 400% $20,120 $27,214 $34,307 $41,400 $48,493 $55,586 $62,680 $69,773 $76,866 $83,959 $91,052 $98,146 $105,239 $112,332 500% $21,870 $29,580 $37,290 $45,000 $52,710 $60,420 $68,130 $75,840 $83,550 $91,260 $98,970 $106,680 $114,390 $122,100 600% $25,515 $34,510 $43,505 $52,500 $61,495 $70,490 $79,485 $88,480 $97,475 $106,470 $115,465 $124,460 $133,455 $142,450 700% $26,244 $35,496 $44,748 $54,000 $63,252 $72,504 $81,756 $91,008 $100,260 $109,512 $118,764 $128,016 $137,268 $146,520 800% $26,973 $36,482 $45,991 $55,500 $65,009 $74,518 $84,027 $93,536 $103,045 $112,554 $122,063 $131,572 $141,081 $150,590 1000% $32,805 $44,370 $55,935 $67,500 $79,065 $90,630 $102,195 $113,760 $125,325 $136,890 $148,455 $160,020 $171,585 $183,150 $36,450 $49,300 $62,150 $75,000 $87,850 $100,700 $113,550 $126,400 $139,250 $152,100 $164,950 $177,800 $190,650 $203,500 $40,095 $54,230 $68,365 $82,500 $96,635 $110,770 $124,905 $139,040 $153,175 $167,310 $181,445 $195,580 $209,715 $223,850 $43,740 $59,160 $74,580 $90,000 $105,420 $120,840 $136,260 $151,680 $167,100 $182,520 $197,940 $213,360 $228,780 $244,200 $47,385 $64,090 $80,795 $97,500 $114,205 $130,910 $147,615 $164,320 $181,025 $197,730 $214,435 $231,140 $247,845 $264,550 $51,030$54,675 $69,020$73,950 $87,010$93,225 $105,000$112,500 $122,990$131,775 $140,980$151,050 $158,970$170,325 $176,960$189,600 $194,950$208,875 $212,940$228,150 $230,930$247,425 $248,920$266,700 $266,910$285,975 $284,900$305,250 $58,320 $78,880 $99,440 $120,000 $140,560 $161,120 $181,680 $202,240 $222,800 $243,360 $263,920 $284,480 $305,040 $325,600 $72,900 $98,600 $124,300 $150,000 $175,700 $201,400 $227,100 $252,800 $278,500 $304,200 $329,900 $355,600 $381,300 $407,000 $87,480 $118,320 $149,160 $180,000 $210,840 $241,680 $272,520 $303,360 $334,200 $365,040 $395,880 $426,720 $457,560 $488,400 $102,060 $138,040 $174,020 $210,000 $245,980 $281,960 $317,940 $353,920 $389,900 $425,880 $461,860 $497,840 $533,820 $569,800 $116,640 $157,760 $198,880 $240,000 $281,120 $322,240 $363,360 $404,480 $445,600 $486,720 $527,840 $568,960 $610,080 $651,200 $145,800 $197,200 $248,600 $300,000 $351,400 $402,800 $454,200 $505,600 $557,000 $608,400 $659,800 $711,200 $762,600 $814,000 $29,160 $39,440 $49,720 $60,000 $70,280 $80,560 $90,840 $101,120 $111,400 $121,680 $131,960 $142,240 $152,520 $162,800 contiguousstates_updatedJan.2022

2023PovertyGuidelines:48ContiguousStates(allstatesexceptAlaskaandHawaii) PerMonth Household/ FamilySize 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Household/ FamilySize 1 2 3 4 5 6 7 8 9 10 11 12 13 14 135% 150% 185%25% 50% 75% 100% 125% 130% 133% 138% 175% 180% 200% $1,215 $1,643 $2,072 $2,500 $2,928 $3,357 $3,785 $4,213 $4,642 $5,070 $5,498 $1,677 $2,268 $2,859 $3,450 $4,041 $4,632 $5,223 $5,814 $6,406 $6,997 $7,588 $2,248 $3,040 $3,833 $4,625 $5,417 $6,210 $7,002 $7,795 $8,587 $9,380 $10,172 $608 $822 $1,036 $1,250 $1,464 $1,678 $1,893 $2,107 $2,321 $2,535 $2,749 $911 $1,233 $1,554 $1,875 $2,196 $2,518 $2,839 $3,160 $3,481 $3,803 $4,124 $1,519 $2,054 $2,590 $3,125 $3,660 $4,196 $4,731 $5,267 $5,802 $6,338 $6,873 $1,580 $2,136 $2,693 $3,250 $3,807 $4,364 $4,921 $5,477 $6,034 $6,591 $7,148 $1,616 $2,186 $2,755 $3,325 $3,895 $4,464 $5,034 $5,604 $6,173 $6,743 $7,313 $1,640 $2,219 $2,797 $3,375 $3,953 $4,532 $5,110 $5,688 $6,266 $6,845 $7,423 $1,823 $2,465 $3,108 $3,750 $4,393 $5,035 $5,678 $6,320 $6,963 $7,605 $8,248 $2,126 $2,876 $3,625 $4,375 $5,125 $5,874 $6,624 $7,373 $8,123 $8,873 $9,622 $2,187 $2,958 $3,729 $4,500 $5,271 $6,042 $6,813 $7,584 $8,355 $9,126 $9,897 $2,430 $3,287 $4,143 $5,000 $5,857 $6,713 $7,570 $8,427 $9,283 $10,140 $10,997 $304 $411 $518 $625 $732 $839 $946 $1,053 $1,160 $1,268 $1,375 ~c;Q,}7 $9,533 $10,175 $11,757 $12,549 $3,178 $3,392 $4,766 $5,088 $6,355 $6,783 $7,944 $8,479 $8,262 $8,818 $8,452 $9,022 $8,579 $9,158 $8,770 $9,361 $11,121 $11,871 $11,439 $12,210 $12,710 $13,567 $1,589 $1,696 400% 500% 600% 700% 1000%225% 250% 275% 300% 325% 350% 375% 800% $4,556 $6,163 $7,769 $8,505 $11,503 $14,502 $17,500 $20,498 $23,497 $26,495 $29,493 $32,492 $35,490 $38,488 $41,487 $44,485 $47,483 $12,150 $16,433 $20,717 $25,000 $29,283 $33,567 $37,850 $42,133 $46,417 $50,700 $54,983 $59,267 $63,550 $67,833 $2,734 $3,698 $4,661 $5,625 $6,589 $7,553 $8,516 $9,480 $10,444 $11,408 $12,371 $13,335 $14,299 $15,263 $3,038 $4,108 $5,179 $6,250 $7,321 $8,392 $9,463 $10,533 $11,604 $12,675 $13,746 $14,817 $15,888 $16,958 $3,341 $4,519 $5,697 $6,875 $8,053 $9,231 $10,409 $11,587 $12,765 $13,943 $15,120 $16,298 $17,476 $18,654 $3,645 $4,930 $6,215 $7,500 $8,785 $10,070 $11,355 $12,640 $13,925 $15,210 $16,495 $17,780 $19,065 $20,350 $3,949 $5,341 $6,733 $8,125 $9,517 $10,909 $12,301 $13,693 $15,085 $16,478 $17,870 $19,262 $20,654 $22,046 $4,253 $5,752 $7,251 $4,860 $6,573 $8,287 $10,000 $11,713 $13,427 $15,140 $16,853 $18,567 $20,280 $21,993 $23,707 $25,420 $27,133 $6,075 $8,217 $10,358 $12,500 $14,642 $16,783 $18,925 $21,067 $23,208 $25,350 $27,492 $29,633 $31,775 $33,917 $7,290 $9,860 $12,430 $15,000 $17,570 $20,140 $22,710 $25,280 $27,850 $30,420 $32,990 $35,560 $38,130 $40,700 $9,720 $13,147 $16,573 $20,000 $23,427 $26,853 $30,280 $33,707 $37,133 $40,560 $43,987 $47,413 $50,840 $54,267 $8,750$9,375 $10,249$10,981 $11,748$12,588 $13,248$14,194 $14,747$15,800 $16,246$17,406 $17,745$19,013 $19,244$20,619 $20,743$22,225 $22,243$23,831 $23,742$25,438 contiguousstates_updatedJan.2022

·' ,. AMENDMENT TOTHEOHIORULES OFCIVILPROCEDURE -APPENDIXOFFORMS PursuanttoitsauthorityunderRule84oftheRulesofCivilProcedure,thefollowingamendments totheAppendixofFormsoftheOhioRulesofCivilProcedure(Form20)wereadoptedbytheSupreme Court.Thehistoryoftheseamendmentsisasfollows: April12,2022 April15,2022 Finaladoptionbyconference Effectivedateofamendments KeytoAdoptedAmendments: 1.Unalteredlanguageappearsinregulartype.Example:text 2. Languagethathasbeendeletedappearsinstrikethrough.Example:~ 3.Newlanguagethathasbeenaddedappearsinunderline.Example:text