IN THE COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

) ) ) ) ) ) ) ) )	CASE NO.
Plaintiff,
vs.	JUDGE
Defendant	Fee Waiver Affidavit Pursuant to R.C. 2323.311

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 / Groceries	$	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 (Specify)	$
Total Column A Expenses	$	Total Column B Expenses	$
TOTAL MONTHLY EXPENSES (Column A + Column B)	$

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 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 .

____________________________________

Notary Public

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.

____________________________________________________________________________________________

APPENDIX
2022 FEDERAL POVERTY LIMIT (FPL)

Persons in family/household	100% Poverty	100% Poverty Monthly Gross Income	187.5% Poverty	187.5% Poverty Monthly Gross Income
1	$13,590	$1,132.50	$25,481.25	$2,123.44
2	$18,310	$1,525.83	$34,331.25	$2,860.94
3	$23,030	$1,919.17	$43,181.25	$3,598.44
4	$27,750	$2,312.50	$52,031.25	$4,335.94
5	$32,470	$2,705.83	$60,881.25	$5,073.44
6	$37,190	$3,099.17	$69,731.25	$5,810.94
7	$41,910	$3,492.50	$78,581.25	$6,548.44
8	$46,630	$3,885.83	$87,431.25	$7,285.94

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 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)