IN THE IOWA DISTRICT COURT FOR POLK COUNTY



In the Iowa District Court for Polk CountyState of Iowa, Plaintiff,v.______________________________________, Defendant.Criminal No: ________________Financial Affidavit & Request for a Court-Appointed LawyerI ask the court to appoint a lawyer for me. To support this request, under penalty of perjury, I swear that:My name is: _____________________________________My date of birth is: _________________________My email address is: ______________________________My cell phone number is: ____________________My home address is: ________________________________________________________________________ Street/ P.O. Box Apt. # City State Zip CodeI support _____ family members. I have: Full Time Job(s) Part Time Job(s) No Job(s) At AllI work for: ________________________________________________________________________________ Employer’s Name(s)Before taxes, I earn:_____________________________________ at this job in a Year Month HourBefore taxes, my partner earns:____________________________________ in a Year Month HourIn addition to this income, the only other money my family makes is:__________________________________________________________________________________________List all other family income including financial payments from a trust fund, disability income, social security, unemployment benefits, food stamps, or other income.____________________________________________________________________________________________________________________________________________________________________________________The only things I own worth more than $500 are:__________________________________________________________________________________________List all houses or other buildings you own, bank accounts, cars, trucks or other vehicles, cash, or anything else worth more than $500.____________________________________________________________________________________________________________________________________________________________________________________My monthly expenses are:__________________________________________________________________________________________List house payments, or rent, car payments, child support, credit card debt or other monthly bills or expenses.____________________________________________________________________________________________________________________________________________________________________________________I understand that I must report any changes to the information above. I understand that if the court appoints an lawyer for me, I may be required to repay the State of Iowa for all or part of the costs of the lawyer. I swear or affirm, under penalty of perjury, that all of the information on this form is true and that I am unable to pay a lawyer on my own._________________________________________________________________________DefendantDate ................
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