Financial Disclosure Form

($25.00 application fee may be assessed — see notice in Section VIII)

This is the Financial Disclosure Form for Fairfield County Common Pleas Court. This form is used to determine whether you qualify for court-appointed legal counsel based on your financial situation. By submitting this form, a non-refundable $25.00 application fee may be assessed unless waived by the court. The form has twelve sections. Section one collects your personal information including name, date of birth, address, and contact details. Section two asks about other persons living in your household. Section three covers presumptive eligibility, such as whether you receive benefits like Medicaid, SSI, or Food Stamps. Section four asks about your monthly income from employment and other sources. Section five asks about your liquid assets such as bank accounts and investments. Section six asks about your monthly expenses including rent, food, utilities, and transportation. Sections seven through eleven contain legal notices and certifications you should read carefully. Section twelve is for juvenile cases only and asks about parents' income for recoupment purposes only. Please have the following ready before you begin: your Social Security Number last four digits, case number, employer information, monthly income figures, asset values, and monthly expense amounts. You will be asked to certify that all information provided is true, and that providing false information may result in criminal charges under Ohio Revised Code sections 120.05 and 2921.13.
I. Personal Information
Enter last 4 digits of Social Security Number only
Race (select all that apply)
II. Other Persons Living in Household
# Name D.O.B. Relationship
1
2
3
4
III. Presumptive Eligibility

The appointment of counsel is presumed if the person represented meets any of the qualifications below. Mark all that apply:

Presumptive eligibility qualifications
IV. Income and Employer

Do not include spouse's income if spouse is alleged victim.

Type of Income Applicant Spouse Total Income
Gross Monthly Employment Income
Unemployment, Worker's Compensation, Child Support, Other Types of Income
TOTAL INCOME
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 Costs of Caring for Infirm Family Member Credit Card, Other Loans
Rent / Mortgage Utilities (Gas, Electric, Water/Sewer, Trash)
Food Other (Specify)
TOTAL LEFT EXPENSES TOTAL RIGHT 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 $25.00 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. 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.
  5. I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge.
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.

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).

XII. Juvenile's Parents' Income — For Recoupment Purposes Only — Not for Appointment of Counsel

Do not include parents' income if parent or relative is alleged victim. Please also complete Section VI if you would like the court to consider monthly expenses when determining the amount of recoupment.

Type of Income Custodial Parent Total
Employment Income (Gross)
Unemployment, Workers Compensation, Child Support, Other Types of Income
TOTAL INCOME

OPD-206R rev. 09/2017