Establishing secure connection…Loading editor…Preparing document…

Affidavit of Indigency Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY

($25.00 application fee may be assessed—see notice on reverse side)

I. PERSONAL INFORMATION

Applicant’s Name
 D.O.B.
 Person Represented’s Name (if juvenile)
 D.O.B.
Mailing Address
 City
 State
 Zip Code
Case No.
 Phone
 Cell Phone

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’

IV. INCOME AND EMPLOYER

Applicant Spouse
(Do not include spouse’s income if spouse is alleged victim)		 Total Income
Gross Monthly Employment Income
Unemployment, Worker’s Compensation, Child Support, Other Types of Income
TOTAL 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 OutTelephone
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 MemberCredit Card, Other Loans
Rent / MortgageUtilities (Gas, Electric, Water / Sewer, Trash)
FoodOther (Specify)
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 / Affidavit of Indigency 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 seven (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. AFFIDAVIT OF INDIGENCY

I, being duly sworn, 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.

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.

Affiant’s signature

Date

Notary Public / Individual duly authorized to administer oath:

Subscribed and duly sworn before me according to law, by the above named applicant this day of , , at , County of , State of Ohio.

Signature of person administering oath

Title (example: Notary, Deputy Clerk of Courts, etc.)

X. JUDGE CERTIFICATION

I hereby certify that above-noted applicant is unable to fill out and / or sign this financial disclosure / affidavit 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 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

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. 01/2012    P.C. Docs. #353441

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Affidavit of Indigency Form Is and Where It’s Used

An Affidavit of Indigency Form is a sworn written statement a person files to request fee waivers or reduced-cost court services when they cannot reasonably afford filing costs, court fees, or other statutory charges. The affidavit documents income, assets, household composition, and monthly expenses under penalty of perjury and typically accompanies a motion or court filing seeking a fee waiver or appointment of counsel. Courts and administrative agencies use the form to assess eligibility for fee relief, public benefits, or pro bono assistance. Requirements and supporting documents vary by jurisdiction and case type.

Why an Accurate Affidavit of Indigency Matters

An accurate affidavit enables courts and agencies to assess fee-waiver eligibility and prevents delays in case processing.

Why an Accurate Affidavit of Indigency Matters

Who Typically Files or Reviews This Form

Agencies and courts rely on the affidavit as an evidentiary baseline; additional documents (pay stubs, benefit letters) are often required to substantiate claims.

  • Self-represented litigants seeking court filing fee waivers or appointment of counsel.
  • Public defenders, legal aid organizations, or pro bono coordinators evaluating client eligibility.
  • Clerks, judges, or administrative officers verifying financial eligibility and attached documentation.

Step-by-step: Completing and Submitting the Affidavit

Follow these practical steps to prepare, verify, and file an Affidavit of Indigency with a court or administrative office.

  • 01
    Gather documents: Collect pay stubs, benefit letters, bank statements, and ID to support your statements.
  • 02
    Complete form: Fill every required field accurately and use MM/DD/YYYY for dates.
  • 03
    Sign and notarize: Sign under penalty of perjury; notarize if the jurisdiction requires a jurat or acknowledgment.
  • 04
    File with court: Submit the affidavit with the motion or filing and provide copies to opposing parties if required.

How to customize an online affidavit workflow

Set up an online workflow to collect sworn statements, required attachments, and reviewer notifications while preserving an audit trail.

Field Configuration
Full Legal Name Required text field; enable auto-fill for returning users
Income Details Repeatable section with numeric validation and currency format
Attachments Allow PDF, JPG uploads; require at least one supporting document
Signature Block Require signer auth and capture timestamp and IP

Where the affidavit goes after you finish it

Understand routing and destination options so the affidavit arrives at the right office and triggers the correct review workflow.

  • Court Clerk: File with the court clerk as part of a fee-waiver motion or initial filing.
  • Assigned Judge: Clerk forwards to the judge or magistrate for eligibility review and decision.
  • Opposing Party: Provide copies to opposing counsel if local rules require service of fee-waiver motions.
  • Legal Aid Office: Send to counsel or legal aid for intake and verification when seeking appointment.

Sharing and eSubmission options for the Affidavit

Confirm the receiving office’s preferred submission method in advance to avoid rejected filings or processing delays.

  • Paper Filing: Print, sign, notarize if required, and deliver or mail per court instructions.
  • Electronic Filing: Upload to the court’s e-filing portal; follow required PDF/A and signature format rules.
  • eSignature + RON: Use eSignature plus remote online notarization where state law permits and the court accepts RON.

Timing and critical deadlines to track

Different filings have different timing rules; here are common deadlines and timing considerations to plan for when submitting an affidavit.

File with initial submission:

Attach the affidavit when you first file the complaint or motion to avoid separate motions later.

Hearing scheduling window:

Courts may set expedited hearings for fee-waiver requests; expect notice within days to weeks.

Deadline to supplement:

Provide additional evidence promptly if the judge requests documentation to support indigency claims.

Response from court:

Some courts issue an order within 14–30 days; timing varies by caseload and local rules.

Appeal or rehearing timeline:

If denied, filing deadlines for rehearing or appeal follow local appellate rules and courthouse schedules.

Key processing milestones from filing to decision

Track these sequential milestones so you know when action or follow-up is likely required during review of your affidavit.

01

Submission

Affidavit and supporting documents are filed with the court or agency.

02

Clerk Screening

Clerk confirms completeness and assigns for judicial review or requests more information.

03

Judicial Review

Judge or designated official evaluates eligibility and applicable statutes or local rules.

04

Order Issued

Court issues an order granting, denying, or conditionally granting a fee waiver.

Common errors that delay review or lead to denials

  • Incomplete income reporting: failing to list all income sources or using gross rather than net income creates inaccurate eligibility assessments and may prompt requests for clarification.
  • Missing supporting documents: failing to attach pay stubs, benefit letters, or bank statements commonly results in administrative rejection or requests to produce documents before review.
  • Unsigned or improperly notarized forms: unsigned affidavits or missing jurat/acknowledgment when required will be rejected and need re-filing, causing delays.
  • Vague expense descriptions: listing 'living expenses' without itemized amounts and proof makes it difficult for adjudicators to evaluate true inability to pay.

Consequences of inaccurate or fraudulent affidavits

Perjury Exposure: Criminal or civil penalties
Fee Denial: Loss of waiver benefits
Sanctions: Court fines or case sanctions
Refile Requirement: Must correct and refile documents
Case Delay: Extended litigation timelines
Reputational Risk: Negative record with court

Essential personal and case data to include

Full Name: Legal name as on ID
Date of Birth: MM/DD/YYYY format
Residential Address: Street, city, state, ZIP
Income Summary: Net monthly income
Household Size: Number of dependents
Supporting Documents: Pay stubs, benefit letters

Core elements every professional Affidavit of Indigency should include

Ensure the form contains clear declarant information, a detailed financial narrative, and verifiable supporting statements so adjudicators can make prompt determinations.

Declarant Information

Full legal name, date of birth, address, contact information, and case identification so the court can associate the affidavit with the proper file and individual.

Household Composition

List all household members, relationships, and dependents to accurately allocate household income and assess need for fee relief or benefits.

Income Details

Itemize all income streams—wages, public benefits, child support, unemployment—using net monthly figures and specifying frequency for correct eligibility calculation.

Monthly Expenses

Provide itemized recurring expenses (rent, utilities, medical, transportation) with amounts to demonstrate the gap between income and basic living costs.

Supporting Attachments

Attach pay stubs, benefit award letters, bank statements, or ID to corroborate statements; unsourced assertions are frequently questioned.

Sworn Statement and Jurat

Include a jurat or notarized signature block where required; the affidavit must be executed under penalty of perjury with date and signature.

Real-world examples of how an Affidavit of Indigency is used

These two concise case summaries show typical contexts and outcomes when a properly completed affidavit is submitted.

Eviction Defense

A tenant files an affidavit with rental income, unemployment documentation, and bank statements

  • Judge grants temporary waiver for filing fees
  • The waiver allowed expedited access to counsel and postponed eviction proceedings while eligibility was reviewed and support resources were arranged.

Appeal Filing

An appellant submits sworn indigency details alongside prior counsel records

  • Clerk accepts filing without prepayment of appeal fee
  • The appellate court docketed the appeal and instructed the appellant to provide updated financial documents before the merits briefing schedule began.

eSignature vendor comparison for submitting and notarizing affidavits

Vendor pricing and core features vary; the table below compares starting price, trial availability, bulk send, audit trail, HIPAA compliance, and envelope limits to help evaluate providers for affidavit workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions about the Affidavit of Indigency Form

Answers to common procedural and compliance questions to reduce filing errors and improve chances of a favorable administrative or judicial response.


Need help? Contact support

Explore Templates

IRS Form 990 Deadline Financial Affidavit and Application for Court Appointed Counsel Civil Cover Sheet Petition for Waiver of Parental Notification of Minor's Abortion Notice of Appeal Affidavit Iowa
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.