VIII. $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.
IX. APPLICANT CERTIFICATION
I, _______________________________________________ (applicant or alleged delinquent child)
I am financially unable to retain private counsel without substantial hardship to me or my family.
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.
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.
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.
I hereby certify that the
information I have provided on this financial disclosure form is true to the best of my
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.
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 applican
t 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, Workers Compensation,
Child Support, Other Types of 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. 09/2017
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