On September 30, 2011 a
Party Statement
was filed
involving a dispute between
State Of Ohio,
and
Eric Demetrus Chase,
for 30-SEP-11
in the District Court of Montgomery County.
Preview
ELECTRONICALLY FILED
ce COURT OF COMMON PLEAS
a
FINANCIAL DISCLOSURE / AFFIDAVI 27, 2013 3:51:47 PM
T
(525.00 application fee may be assessed—see n eon e cage ip Agee
tr ri art Fr
Applicant’s Name
> Person Represented’s Name (ifjuvenile)
0.0.8.
tc Chase 1ofis/ 199
0.0.8.
‘Address
TAD Lito
Case No.
oe Title
Phone
( )
Heights On
Cell Phone
[Stay
2) ee a) eI,
Name 0.0.8, Relationship Name
4) 0.0.8. Relationship
3)
2)
4)
a aat a ting
The appointment of counsel is presumed
if the person repi resented meets any of the qualifi
cations below. Please place an *
Ohio Works First/ TANF: SSI: SSD: “Medicaid: Poverty Related Veterans’ Benefits: Food Stamps:
Refugee Settlement Benefits: Incarcerated in state penitentiary: Committed to a Public Mental Health Facility:
Other (please describe}:
Juvenile: (if Juvenile, pleaseeodtinue ‘at Section Vill)
A ee yavloteyy
acy
Applicant Spouse
(Do not include spouse’s income if spouse is alleged victim) Total Income
Gross Monthly Employment income
~
a
Unemployment, Worker's Compensation, Child
Support, Other Types
+ Income
2% 2
THOS a 5 TT?
tern
fh
TOTAL INCOME $
EmplogersNarna TOU ~ my
Cio 20 3ar Phone Number:
Employeris-Address-—--—
san voi TL
ts
ry ny
Type of ‘
Estimated Value
Checking, Sasdags Manayddarket AccoURIG =
10
Stocks, Bonds, CDs § Eo
Other Liquid Assets or Cash on Hand
E>
Total Liquid Assets OT
Type of Expense Amount: Type
of Expense Amount:
Child Support Paid Out Telephone
Child Care (if working only)
ihi Insurance (medical, dental, auto, etc.)
Transportation / Fuel
Taxes Withheld or Owed
—-
" Medical / Dental Expenses or Associated Costs of
Caring for Infirm Family Member
Rent / Mortgage
Credit Card, Other Loans
my
Utilities (Gas, Electric, Water
/ Sewer, Trash)
O-
Food
EXPENSES $
O- Other (Specify)
EXPENSES | $
S
1) r rN fe) fe) >
.
'f 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 x!.
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 Povel tty Guidelines, but applicant is financially unable to employ counsel after paying monthly
expenses in Section VI, counsel must be appointed.
PERE ile) zaaeyiias
submitting-this. Financial Di losure. /.Affidavit-of Indigency.
Form,. -you.will be assessed a non-refundable $25.00 application
walved or reduced by the court. If assessed, the fee fee.untess_|_—_
is to be paid to the clerk of courts within seven (7) days of submitt
entity that will make a determination regarding ing this form to the
your incigency. No applicant may be denied counsel based upon
this fee. failure or Inability to.pay
Sree acl aiia
| yy (applicant or alleged delinquent child) being duly sworn, state:
! am financially unable to retain private counsel without substan
tial hardship to me or my family.
| understand that | must inform the public defen
der or a pointed attorn ey if my financial situation should change
before the disposition of the case(s) for which representation
is being p rovided.
| understand that if it is determined by the count
ty or the court that legal representation should not have been
provided, I may be required to reimburse
the c¢ ‘ounty for the costs of representation provided, Any action
by the county to collect legal fees hereunder must filed
be brought within two yearsfrom the last date legal
representation was provided.
| understand that | am sul bject to criminal charges
for providing fal RSG Soimation in connection with
this application for legal representation, pursuant
to Ohio Revised Code sections 120.05 and 2921.13,
| hereby certify that the information | have provided on this financial disdlasureform is true to the best of my
knowledge.
20 A
Affiant’s signature Date
Notary Public / Individual duly authorized to administer
oath:
Sub ribed and duly sworn before me accordj to law, by the above named appli cg BUEN, da
Ohio.
OL —, OO(?
County of FpWipAA STDS
TSS
BETH C.8¢i
.
ats=) NOTARY PUBL!
fa
Signatureof p 0 Title (example: Notary, De
See Pcie s re Vile)
Se
therebycertify that above-noted applicant is unable to fill out and his
/orsignt! his financial disclosure / affidavit
for the following reason:
. thave determined
that the party represented meets the criteria for receiving court-a
ppointed counsel.
Judge's signature
SP eh ie elgsee
aM oe
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 lo payments, compensation, or in-kind services
shall be required irom an applicant or client
whose income falls below 125% of the federal poverty guidelines. See OAC
120-1-05, 8
Through recoupment, an applicant or client may be required to pay for part of the
cost of services rendered, if he oa ain
reasonably be expected to pay. See ORC §2941.51(D)
Cea ae deeal Lew Lely didi ares eck ey Ts am Ue ee ae Sees
Custodial Parents’ Income (Do not include parents’
Income if parent = relative is alleged victim) Total
Employment income (Gross)
Unemployment, Workers Compensation,
Child Support, Other Types of Income
TOTALINCOME | $
*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.
Sequin rom nsut
Document Filed Date
June 27, 2013
Case Filing Date
September 30, 2011
Status
913 HILE LANE, ENGLEWOOD, OH 45322
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ELECTRONICALLY FILED ce COURT OF COMMON PLEAS a FINANCIAL DISCLOSURE / AFFIDAVI 27, 2013 3:51:47 PM T (525.00 application fee may be assessed—see n eon e cage ip Agee tr ri art Fr Applicant’s Name > Person Represented’s Name (ifjuvenile) 0.0.8. tc Chase 1ofis/ 199 0.0.8. ‘Address TAD Lito Case No. oe Title Phone ( ) Heights On Cell Phone [Stay 2) ee a) eI, Name 0.0.8, Relationship Name 4) 0.0.8. Relationship 3) 2) 4) a aat a ting The appointment of counsel is presumed if the person repi resented meets any of the qualifi cations below. Please place an * Ohio Works First/ TANF: SSI: SSD: “Medicaid: Poverty Related Veterans’ Benefits: Food Stamps: Refugee Settlement Benefits: Incarcerated in state penitentiary: Committed to a Public Mental Health Facility: Other (please describe}: Juvenile: (if Juvenile, pleaseeodtinue ‘at Section Vill) A ee yavloteyy acy Applicant Spouse (Do not include spouse’s income if spouse is alleged victim) Total Income Gross Monthly Employment income ~ a Unemployment, Worker's Compensation, Child Support, Other Types + Income 2% 2 THOS a 5 TT? tern fh TOTAL INCOME $ EmplogersNarna TOU ~ my Cio 20 3ar Phone Number: Employeris-Address-—--— san voi TL ts ry ny Type of ‘ Estimated Value Checking, Sasdags Manayddarket AccoURIG = 10 Stocks, Bonds, CDs § Eo Other Liquid Assets or Cash on Hand E> Total Liquid Assets OT Type of Expense Amount: Type of Expense Amount: Child Support Paid Out Telephone Child Care (if working only) ihi Insurance (medical, dental, auto, etc.) Transportation / Fuel Taxes Withheld or Owed —- " Medical / Dental Expenses or Associated Costs of Caring for Infirm Family Member Rent / Mortgage Credit Card, Other Loans my Utilities (Gas, Electric, Water / Sewer, Trash) O- Food EXPENSES $ O- Other (Specify) EXPENSES | $ S 1) r rN fe) fe) > . 'f 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 x!. 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 Povel tty Guidelines, but applicant is financially unable to employ counsel after paying monthly expenses in Section VI, counsel must be appointed. PERE ile) zaaeyiias submitting-this. Financial Di losure. /.Affidavit-of Indigency. Form,. -you.will be assessed a non-refundable $25.00 application walved or reduced by the court. If assessed, the fee fee.untess_|_—_ is to be paid to the clerk of courts within seven (7) days of submitt entity that will make a determination regarding ing this form to the your incigency. No applicant may be denied counsel based upon this fee. failure or Inability to.pay Sree acl aiia | yy (applicant or alleged delinquent child) being duly sworn, state: ! am financially unable to retain private counsel without substan tial hardship to me or my family. | understand that | must inform the public defen der or a pointed attorn ey if my financial situation should change before the disposition of the case(s) for which representation is being p rovided. | understand that if it is determined by the count ty or the court that legal representation should not have been provided, I may be required to reimburse the c¢ ‘ounty for the costs of representation provided, Any action by the county to collect legal fees hereunder must filed be brought within two yearsfrom the last date legal representation was provided. | understand that | am sul bject to criminal charges for providing fal RSG Soimation in connection with this application for legal representation, pursuant to Ohio Revised Code sections 120.05 and 2921.13, | hereby certify that the information | have provided on this financial disdlasureform is true to the best of my knowledge. 20 A Affiant’s signature Date Notary Public / Individual duly authorized to administer oath: Sub ribed and duly sworn before me accordj to law, by the above named appli cg BUEN, da Ohio. OL —, OO(? County of FpWipAA STDS TSS BETH C.8¢i . ats=) NOTARY PUBL! fa Signatureof p 0 Title (example: Notary, De See Pcie s re Vile) Se therebycertify that above-noted applicant is unable to fill out and his /orsignt! his financial disclosure / affidavit for the following reason: . thave determined that the party represented meets the criteria for receiving court-a ppointed counsel. Judge's signature SP eh ie elgsee aM oe 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 lo payments, compensation, or in-kind services shall be required irom an applicant or client whose income falls below 125% of the federal poverty guidelines. See OAC 120-1-05, 8 Through recoupment, an applicant or client may be required to pay for part of the cost of services rendered, if he oa ain reasonably be expected to pay. See ORC §2941.51(D) Cea ae deeal Lew Lely didi ares eck ey Ts am Ue ee ae Sees Custodial Parents’ Income (Do not include parents’ Income if parent = relative is alleged victim) Total Employment income (Gross) Unemployment, Workers Compensation, Child Support, Other Types of Income TOTALINCOME | $ *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. Sequin rom nsut