Free The Ohio Judicial Center 65 South Front Street, Third Floor Columbus, OH 43215 6... - Ohio

The Ohio Judicial Center 65 South Front Street, Third Floor Columbus, OH 43215 614. 387.9800 or 1.800.824.8263 www.cco.state.oh.us

Poverty Statement (Affidavit)

Plaintiff V. Case Number Judge

Defendant

I,

, state under the penalties of perjury

and falsification that I am indigent and that payment of the $25.00 filing fee would create a financial hardship for me.

Plaintiff's signature*

Date

*Under R.C. 2921.11,R. .C. 2929.11 and 2929.18 perjury is a felony of the third degree and punishable by imprisonment of one to five years and a fine up to $10,000.00 Under R.C. 2921.13 and R.C. 2929.21 falsification is a misdemeanor of the first degree and punishable by imprisonment of six months and a fine not more than $1,000.00.

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