AFFIDAVIT OF INDIGENCY
AFFIDAVIT OF INDIGENCY Revised: 7-7-09
Request for court appointed counsel verified: Yes No Spanish Only
Name: Case No.
Address: CID No.
City: Zip code:
Phone number:
DOB: Age: Race: Sex: Male Female
Are you married? Yes No Name of spouse:
DEPENDENT INFORMATION
How many people do you support? How many people live with you?
Name Age Relationship Living with you Y/N Income
EMPLOYMENT INFORMATION
If employed:
Employer’s Name: ___________________________ Length of Employment
Amount paid $ : How paid? (___) Monthly- amount x 12 (___) Daily x no. days worked
(___) Twice monthly- amount x 24; (___) Every two weeks- amount x 26; (___) Weekly- amount x 52
Address: Phone Number:
Supervisor’s Name:
If unemployed:-
How long? Reason for unemployment
Name of previous employer:
Does anyone support you? Yes No
If yes answer the following -
Name: Age: Relation:
Address: Phone:
Do you live with them? Yes No Where do they work?
|Income |Amount |
|Gross Pay | |
|Spouse’s Pay | |
|Investment Income | |
|Stock Dividend | |
|Bond Dividend | |
|Rental Income | |
|Pension Payments | |
|Unemployment | |
|Social Security Benefits | |
|Child Support | |
|Public Assistance | |
|TANF (Welfare-Food Stamps) | |
|SSI (Social Security) | |
|Medicaid (yes or no) | |
|WIC (women, infant and children) | |
|Cash Gifts | |
|Other | |
|Total Gross Monthly Income | |
|Total Gross Annual Income | |
|Assets |Amount |
|Residence Amount Owed | |
| Market Value | |
|Other Real Property: | |
|Type/Location | |
|1. | |
|Other Property | |
|(Identify jewelry, equipment, watercrafts, | |
|stocks, Bonds, ETC.) | |
|Automobile | |
|Make Model Year | |
|1. | |
|2. | |
|Bank Accounts |Balance |
|Bank Name ----- Type | |
|1. | |
|2. | |
|Total Asset Value: | |
COURT FINDING:
Indigent Insufficient Information
Not Indigent No Finding______________
Charges dropped Withdrew Request
_____________________________________________
Judge’s Signature Date: _____________
|Expenses (Monthly) | |
|Rent or Mortgage Payment | |
|If owned value | |
|Car Payment ( How many?______ ) | |
|Insurance (Life, Health, Car, Homeowners, | |
|etc.) | |
|Child Care | |
|Child Support | |
|Water | |
|Gas – Home | |
|Gas – Automobile | |
|Telephone | |
|Electricity | |
|Food | |
|Clothes | |
|Medical | |
|Cable TV or Satellite TV | |
|Cell Phone/Pager | |
|Charge accounts and other Payments: |
|1. | |
|2. | |
|3. | |
|4. | |
|Total Monthly Expenses | |
| | |
Credit card/Type Available limit Credit Balance
| | |
| | |
Notes:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
By signing my name below, I swear, that all of the above information about my financial condition is current, accurate and true. By signing below, I understand that a court official can verify any of the information for accuracy as required to determine my eligibility.
Defendant’s Signature
______________________________________________
Financial Officer’s Signature Date: ___________
Defendant in custody: YES NO
................
................
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