Accessible: Wayne-County-Domestic-Relations-Form-38.pdf

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Telephone Child Care (if working only) Transportation/Fuel Insurance (medical, dental, auto, etc.) Taxes Withheld/Owed Mental/Dental Expenses or Associated Costs of caring for Infirm Family Member Credit Card/Other Loans Rent/Mortgage Utilities (gas, electric, water, sewer, trash) Food Other (specify) FINANCIAL DISCLOSURE FORM ($25.00 application fee may be assessed—see notice on reverse side) I. PERSONAL INFORMATION Applicant’s Legal Name Mailing Address State SSN Last 4GenderRace (double-click to de-select) ☐ Zip Code Case No. Phone Cell Phone Applicant’s Preferred Name and Pronoun City Date of Birth Email Address American Indian or Alaskan Native ☐Spanish or Latino ☐Asian ☐White ☐Black or African American ☐Other ☐Native Hawaiian or Pacific Islander Name 1) 2) DOB Relationship Name DOB Relationship 3) 4) The appointment of counsel is presumed if the person represented meets any of the qualifications below. Please place an “X” if: Ohio Works First/TANF: SSI: SSD: Medicaid: Poverty Related Veteran’s Benefits: Food Stamps: Refugee Settlement Benefits: Incarcerated in State Penitentiary: Committed to a Public Mental Health Facility: Juvenile: (If juvenile, please continue at Section VIII)Other (please describe): IV. INCOME AND EMPLOYER Applicant $ $ Gross Monthly Employment Income Unemployment, Worker’s Compensation, Child Support, Other Typers of Income Spouse (Do not include spouse’s income if spouse is alleged victim) Total Income TOTAL INCOME $ $ $ $ $ Employer’s Name: P h o n e N u m b e r : ( ) Employer’s Address: V. LIQUID ASSETS Type of Asset Estimated Value Checking, Savings, Money Market Accounts Other Liquid Assets or Cash on Hand Stocks, Bonds, CDs $ $ $ $TOTAL LIQUID ASSETS VI. MONTHLY EXPENSES Type of Expense Amount Type of Expense Amount Child Support Paid Out VII. DETERMINATION OF INDIGENCY EXPENSES EXPENSES $ 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. $ $ $ $ $ $ $ $ $ $ $ $ $ II. OTHER PERSONS LIVING IN HOUSEHOLD III. PRESUMPTIVE ELIGIBILITY

VII. $25.00 APPLICATION FEE NOTICE By submitting this Financial Disclosure Form, you will be assessed a non-refundable $25.00 application fee unless waived or reduced by the court. If assessed, the fee is to be paid to the clerk of courts within 7 days of submitting this form to the entity that will make a determination regarding your indigency. No applicant may be denied counsel based upon failure or inability to pay this fee. VII. $25.00 APPLICATION FEE NOTICE IX. APPLICANT CERTIFICATION I, _______________________________________________ (applicant or alleged delinquent child) state: 1. I am financially unable to retain private counsel without substantial hardship to me or my family. 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. 3. I understand that if it is determined by the county or 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. 4. I understand that I am subject to criminal charges for providing false financial information in connection with this application for legal representation, pursuant to Ohio Revised Code sections 120.05 and 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. Name and title of authorized persons completing form on behalf of applicant. Information obtained via phone or video. Signature of applicant Date X. COURT CERTIF ICATION I hereby certify that the above-noted applicant is unable to fill out and/or sign this financial disclosure for the following reason: . I have determined that the party represented meets the criteria for receiving court-appointed counsel. Judge or Magistrate's signature Date XI. NOTICE OF RECOUPMENT ORC. §120.03 allows for county recoupment programs. Any such program may not jeopardize the quality of defense provided or act to deny representation to qualified applicants. No payments, compensation, or in-kind services shall be required from an applicant or client whose income falls below 125% of the federal poverty guidelines. See OAC 120-1-05. Through recoupment, an applicant or client may be required to pay for part of the cost of services rendered, if he or she can reasonably be expected to pay. See ORC §2941.51(D). XII. JUVENILE’S PARENTS’ INCOME* – FOR RECOUPMENT PURPOSES ONLY – NOT FOR APPOINTMENT OF COUNSEL Custodial Parents’ Income (Do not include parents’ income if parent or relative is alleged victim) $ $ Employment Income (gross) Unemployment, Worker’s Compensation, Child Support, Other Typers of Income Total TOTAL INCOME $ $ $ *Please complete Section VI on page 1 of this form if you would like the court to consider your monthly expenses when determining the amount of recoupment which you can reasonably be expected to pay. OPD-206R rev. 2/24