FINANCIAL DISCLOSURE FORM
($25.00 application fee may be assessedsee notice on reverse side)
I. PERSONAL INFORMATION
Applicant’s Name
D.O.B.
Name of Person Being Represented (if juvenile)
D.O.B.
Mailing Address
City
Zip Code
Case No.
Phone
( )
Cell Phone
( )
SSN Last 4
Gender
Race (double-click to de-select)
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander
Spanish or Latino
White Other
II. OTHER PERSONS LIVING IN HOUSEHOLD
Name
1)
D.O.B.
Relationship
Name
3)
D.O.B.
Relationship
2)
4)
III. PRESUMPTIVE ELIGIBILITY
The appointment of counsel is presumed if the person represented meets any of the qualifications below. Please place an ‘X’
Ohio Works First / TANF: ____ SSI: ____ SSD: ____ Medicaid: ____ Poverty Related Veterans’ Benefits: ____ Food Stamps: ____
Refugee Settlement Benefits: ____ Incarcerated in state penitentiary: ____ Committed to a Public Mental Health Facility: ____
Other (please describe): ____________________________________________________________ Juvenile: ____
(if juvenile, please continue at Section VIII)
IV. INCOME AND EMPLOYER
Applicant
Spouse
(Do not include spouse’s income if spouse is alleged victim)
Total Income
Gross Monthly Employment Income
Unemployment, Workers Compensation, Child
Support, Other Types of Income
$
Employer’s Name: ______________________________________________________ Phone Number: ( ) _____________________________
Employer’s Address: _______________________________________________________________________________________________________
V. LIQUID ASSETS
Type of Asset
Estimated Value
Checking, Savings, Money Market Accounts
$
Stocks, Bonds, CDs
$
Other Liquid Assets or Cash on Hand
$
Total Liquid Assets
$
VI. MONTHLY EXPENSES
Type of Expense
Amount
Type of Expense
Amount
Child Support Paid Out Telephone
Child Care (if working only) Transportation / Fuel
Insurance (medical, dental, auto, etc.) Taxes Withheld or Owed
Medical / 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)
EXPENSES
$
EXPENSES
$
VII. DETERMINATION OF INDIGENCY
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.
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL INCOME
$
-
-
-
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)
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.
5.
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
knowledge.
_____________________________________________________________ _______________________
Signature
Date
X. JUDGE CERTIFICATION
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’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 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 PARENTSINCOME* FOR RECOUPMENT PURPOSES ONLY NOT FOR APPOINTMENT OF COUNSEL
Custodial Parents Income (Do not include parents
income if parent or relative is alleged victim)
Total
Employment Income (Gross)
Unemployment, Workers Compensation,
Child Support, Other Types of Income
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. 09/2017
$
$
$
$
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