Fillable Bowling Green, Ohio Wood County Court of Common (Fairfield County)

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Bowling Green, Ohio Wood County Court of Common (Fairfield County)

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Form 20 – Civil Fee Waiver Affidavit and Order
Effective: April 15, 2020.
Wood County Court of Common Pleas
Bowling Green, Ohio
______________________________
Plaintiff
vs.
____________________________________
Defendant
)
)
)
)
)
)
)
)
CASE NO.
JUDGE
FINANCIAL DISCLOSURE / FEE-
WAIVER AFFIDAVIT
AND ORDER
Pursuant to R.C. 2323.311, the below-named Applicant requests that the Court determine that the Applicant
is an indigent litigant and be granted a waiver of the prepayment of costs or fees in the above captioned
matter. The Applicant submits the following information in support of said request.
Personal Information
Applicant’s First Name
Applicant’s Last Name
Applicant’s Date of Birth
Last 4 Digits of Applicant’s SSN
Applicant’s Address
Other Persons Living in Your Household
Last Name
Is this person a child
under 18?
Relationship (Spouse or Child)
□ Yes ☐ No
□ Yes ☐ No
□ Yes ☐ No
Public Benefits
I receive the following public benefits and my gross income, including the cash benefits marked below, does not
exceed 187.5% of the federal poverty guidelines.
Place an “X” next to any benefits you receive.
Ohio Works First
1
: SSI
2
: Medicaid
3
: Veterans Pension Benefit
4
: SNAP / Food Stamps
5
: ____
Monthly Income
I am NOT able to access my spouse’s income ☐
Applicant
Spouse (If Living
in Household)
Total Monthly Income
Form 20 – Civil Fee Waiver Affidavit and Order
Effective: April 15, 2020.
Gross Monthly Employment Income,
including Self-Employment Income
(Before Taxes)
$
$
$
Unemployment, Worker’s Compensation,
Spousal Support (If Receiving)
$
$
$
TOTAL MONTHLY INCOME
$
Liquid Assets
Type of Asset
Estimated Value
Cash on Hand
$
Available Cash in Checking, Savings, Money Market
Accounts
$
Stocks, Bonds, CDs
$
Other Liquid Assets
$
Total Liquid Assets
$
Monthly Expenses
Column A
Column B
Type of Expense
Amount
Type of Expense
Amount
Rent / Mortgage / Property Tax /
Insurance
$
Insurance (Medical, Dental,
Auto, etc.)
$
Food / Paper
Products/Cleaning
Products/Toiletries
$
Child or Spousal Support that
You Pay
$
Utilities (Heat, Gas, Electric,
Water / Sewer, Trash)
$
Medical / Dental Expenses or
Associated Costs of Caring for a
Sick or Disabled Family Member
$
Transportation / Gas
$
Credit Card, Other Loans
$
Phone
$
Taxes Withheld or Owed
$
Child Care
$
Other (e.g. garnishments)
$
Total Column A Expenses
$
Total Column B Expenses
$
TOTAL MONTHLY EXPENSES (Column A + Column B)
I, , hereby certify that the information I have provided on
(Print Name)
this financial disclosure form is true to the best of my knowledge and that I am unable to prepay the costs
or fees in this case.
Signature
NOTARY PUBLIC:
Sworn to before me and signed in my presence this day of , 20 ,
in County, Ohio.
Notary Public (Signature)
Notary Public (Printed)
My Commission expires:
If available, an individual duly authorized to administer this oath at the Clerk of Court’s Office will do so
at no cost to the Applicant.
Form 20 – Civil Fee Waiver Affidavit and Order
Effective: April 15, 2020.
APPENDIX
2020 FEDERAL POVERTY LIMIT (FPL)
Persons in
family/household
100% Poverty
100% Poverty
Monthly Gross
Income
187.5% Poverty
187.5% Poverty
Monthly Gross
Income
1
$12,760
$1,063.33
$23,925
$1,993.74
2
$17,240
$1,436.67
$32,325
$2,693.75
3
$21,720
$1,810
$40,725
$3,393.75
4
$26,200
$2,183.33
$49,125
$4,093.75
5
$30,680
$2,556.67
$57,525
$4,793.75
6
$35,160
$2,930
$65,925
$5,493.75
7
$39,640
$3,303.33
$74,325
$6,193.75
8
$44,120
$3,676.67
$82,725
$6,893.75
R.C. 2323.311(B)
(4) A judge or magistrate of the court shall review the affidavit of indigency as filed pursuant to division (B)(2) of this
section and shall approve or deny the applicant's application to qualify as an indigent litigant. The judge or magistrate shall
approve the application if the applicant's gross income does not exceed one hundred eighty-seven and five-tenths per cent
of the federal poverty guidelines as determined by the United States department of health and human services for the state
of Ohio and the applicant's monthly expenses are equal to or in excess of the applicant's liquid assets as specified in
division (C)(2) of section 120-1-03 of the Administrative Code, as amended, or a substantially similar provision. If the
application is approved, the clerk shall waive the advance deposit or security and the court shall proceed with the civil
action or proceeding. If the application is denied, the clerk shall retain the filing of the action or proceeding, and the court
shall issue an order granting the applicant whose application is denied thirty days to make the required advance deposit or
security, prior to any dismissal or other action on the filing of the civil action or proceeding.
(6) Nothing in this section shall prevent a court from approving or affirming an application to qualify as an indigent litigant
for an applicant whose gross income exceeds one hundred eighty-seven and five-tenths per cent of the federal poverty
guidelines as determined by the United States department of health and human services for the state of Ohio, or whose liquid
assets equal or exceed the applicant's monthly expenses as specified in division (C)(2) of section 120-1-03 of the
Administrative Code, as amended, or a substantially similar provision.
1
Ohio Works First Income Limit: 50% FPL (R.C. 5107.10(D)(1)(a))
2
SSI Income Limit: cannot have countable income that exceeds the Federal Benefit Rate (FBR). 2019 FBR: $771
monthly for single disabled individual; $1157 monthly for disabled couple (20 CFR 416.1100)
3
Medicaid Income Limit:
Modified Adjusted Gross Income (MAGI):138% FPL (OAC 5160:1-4-01; 42 USC 1396a(a)(10)(A)(i)(VIII))
Aged, Blind or Disabled: $791 for single person; $1177 for disabled couple
4
Veterans Pension Benefit Income Limit: $13,535 annually / $1,127 monthly for a single person; $17,724 annually /
$1,477 monthly for a veteran with one dependent
5
Supplemental Nutrition Assistance Program (SNAP) Income Limit: 130% FPL for assistance groups with
nondisabled/nonelderly member; 165% FPL for elderly and disabled assistance groups (OAC 5101:4-4-11; Food
Assistance Change Transmittal No. 61)
Form 20 – Civil Fee Waiver Affidavit and Order
Effective: April 15, 2020.
Wood County Court of Common Pleas
Bowling Green, Ohio
_______________________
Plaintiff
vs.
____________________________________
Defendant
)
)
)
)
)
)
)
)
CASE NO.
JUDGE
ORDER
□
Upon the request of the Applicant and the Court’s review, the Court finds that the Applicant IS an
indigent litigant and GRANTS a waiver of the prepayment of costs or fees in this matter. Pursuant to
R.C. 2323.311(B)(3), upon the filing of a civil action or proceeding and the affidavit of indigency
under division (B)(1) of this section, the clerk of the court shall accept the action, motion, or
proceeding for filing.
□
Upon the request of the Applicant and the Court’s review, the Court finds that the Applicant is NOT
an indigent litigant and DENIES a waiver of the prepayment of costs or fees in this matter.
Applicant is granted thirty (30) days from the issuance of this Order to make the required advance
deposit or security. Failure to do so within the time allotted may result in dismissal of the applicant’s
filing.
IT IS SO ORDERED
Judge / Magistrate Date
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Bowling Green, Ohio Wood County Court of Common (Fairfield County)

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Completed 29 November 2021

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