COVER SHEET

I. PERSONAL INFORMATION

II. OTHER PERSONS LIVING IN HOUSEHOLD

Person 1:

Person 2:

Person 3:

Person 4:

III. PRESUMPTIVE ELIGIBILITY

IV. INCOME AND EMPLOYER

Gross Monthly Employment Income

Unemployment, Worker's Compensation, Child Support, Other Types of Income

V. LIQUID ASSETS

VI. MONTHLY 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.

VIII. $25.00 APPLICATION FEE NOTICE

By submitting this Financial Disclosure Form, you will be assessed a non-refundable $25 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 above) 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 criminate 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.

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).

X. COURT CERTIFICATION

*To be completed by Judge or Magistrate

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)

*Please complete Section VI 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.