Ohio Civ.R. Form 20
IN ___________________________________
______________________________________________
) | CASE NO. | |
) | ||
Plaintiff, | ) | JUDGE |
) | ||
vs. | ) | |
) | FINANCIAL DISCLOSURE / FEE- | |
) | WAIVER AFFIDAVIT | |
Defendant. | ) | 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 | |||
First Name | 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: ___ SSI: ___ Medicaid: ___ Veterans Pension Benefit: ___ SNAP / Food Stamps: ___ | |||
Monthly Income | |||
I am NOT able to access my spouse's income[] | |||
Applicant | Spouse (If Living in Household) | Total Monthly Income | |
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) | |||
Ohio Works First Income Limit: 50% FPL (R.C. 5107.10(D)(1)(a))
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)
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
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
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)
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.
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
APPENDIX
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.
Ohio. Civ.R. Form 20