NOTICE OF OBLIGATIONS/RIGHTS OF PARENTS/GUARDIANSA court may order a parent or legal guardian to pay certain costs, inclu ding: - if your child is placed in substitute care, child support you receive for the child will be paid to the state. - the costs to assist in providing appropriate education or counseling f or your child. - cost of out-of-home placement. - costs of a lawyer appointed to represent your child. - cost of service of summons. - daily expenses and mileage fees of certain witnesses. - up to $2,500 toward any restitution your child is obligated to pay a v ictim. - up to $7,500 damages caused by your child to property. - up to $5,000 for forest fires caused by your child. - cost of HIV testing. - cost of graffiti damages caused by your child. - cost of drug and/or alcohol treatment for your child. - cost of detention services for your child.To appeal a circuit courts decision, you must file a notice of appea l with the Court of Appeals within 30days of the entry of the courts final order in the court register. I f you were not represented by a lawyer,you may have longer to file notice of appeal in certain circumstances. S ee ORS 419A.200(4).>>>> 2 IN THE CIRCUI T COU RT OF THE ST ATE OF OR EGON THIRD J UDICI AL DI STRI CT Juvenil e Department PLEASE PRINT LEGIBLY In the Matter of: ) Case No.______________________ ) ) AFFIDAV IT OF INDIGENC Y/REQUEST ) FOR COURT APPOI NTED ATT ORNEY/_______________________________________, ) AGREEMENT TO REP AY a child. ) ) Approve Deny STATE OF OREGON ) ) ss. Charges: __________________________ County of Marion ) __________________________________ I, the undersigned, being duly sworn, say I am the parent/guardian of the youth in the above case. I am asking forappointment of an attorney to represent ________________________ in this case because I cannot pay for anattorney now without causing substantial hardship to myself or my family. The following information is true and Iask the Court to use the information to decide whether I can have an attorney and payment of other costs at publicexpense. I understand that if I dont tell the truth, I may be charged with perjury or false swearing and, if convicted,I may be imprisoned. I am providing my social security number on a voluntary basis. I understand that I cannot becompelled to provide it or be denied consideration solely for failing to provide it. It may be used to verify myidentification, credit and employment information, used for collections purposes, or for any court-imposed monetaryobligation. I. BASI C FAC TS AND HOUSEHOLD I NFORMATI ON: (Parent/Guardian) Full Name ______________________________________________ Date of Birth _______________________Address ________________________________________________ Telephone __________________________Mailing Address ______________________________________ SSN ______________________________ Sex __________ Single Married Separated Divorced Divorce Filed Renting Buying Mobile Home If buying, estimated value $__________ Amount Owed $__________ Owner Name ____________ Who else lives there? (Include children, spouse, other family members, roommates. List name, date of birth,relationship and gross/net monthly income of each): None ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Children living outside your home for whom you must pay Court ordered child support: None ____________________________________________________________________________________________ ____________________________________________________________________________________________ II. INCOME: Are you employed? Yes No If not, how are you supported? _____________________________________List your employment for the last 2 years: Employer Address Dates Employed Monthly Income - NET____________________________________________________________________________________________ ____________________________________________________________________________________________ List spouses employment for the last 2 years: None AFFIDAVIT OF I NDIGENCY/REQUEST FOR COURT APPOINTED ATTO RNEY/AGREEMENT TO REPAY Page 1 of 2 FC(5/18/04)>>>> 3 Source Monthly Income - NET Lis t all sources of income for your family such as retirement, alimony, child support, public assistance, workers compensation, disability, food stamps, social security, etc.: None Source: ___________________________________________________ Monthly Amount: $__________ Source: ___________________________________________________ Monthly Amount: $__________ III. REAL ESTATE: None Description Balanced Owed Equity ____________________________________________________________________________________________ AUTOM OBILES & OTHER MO TOR VEHICLES , owned by you and your spouse: None Make & Year What It Is Worth Amount Owed ____________________________________________________________________________________________ ____________________________________________________________________________________________ BANK ACCO UNTS OR CASH , owned by you and your spouse: None Bank/Branch Balance Cash ____________________________________________________________________________________________ ____________________________________________________________________________________________ ALL OTHER PROPERTY OR ASSET S, (stocks, bonds, buns, boats, jewelry): None Item What It Is Worth Amount Owed ____________________________________________________________________________________________ ____________________________________________________________________________________________ IV. DEBTS None Creditor Amount Owed Monthly Payment Last Paid ____________________________________________________________________________________________ ____________________________________________________________________________________________ MONT HLY EXPENSES None Whom Amount Owed Monthly Payment ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ If I can get a Court Appointed Attorney, I agree to pay the Court back for reasonable attorney fees and costs paid in my defense, as order