IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT STATE OF ALASKA Plaintiff, Defendant. ) ) ) ) ) ) ) ) vs. CASE NO. CR REQUEST FOR APPOINTED ATTORNEY I wish to have an attorney and cannot afford to pay for one. I request that the court appoint an attorney to represent me. I understand that: 1. I must provide to the court all financial information requested by the court so the court can decide if I qualify for an appointed attorney. 2. Financial information I give may be made available to the Attorney General at the end of this case. Any false information I give may be used to prosecute me for perjury under AS11.56.200. 3. If my financial situation changes and I do not tell the court, the law requires my appointed attorney to do so. 4. If I am convicted, the court will enter a judgment against me and require me to pay part of the cost of my appointed attorney. In most cases the court will use the schedule below to decide how much I will be required to pay. However, before the court decides, I will have a chance to ask the judge to lower the amount. After the judgment is entered, I may ask the court to reduce the judgment amount if payment would cause manifest hardship to me or my family. GENERAL WAIVER I authorize anyone to release to the Alaska Court System all information concerning my assets, liabilities, account balances and any income source I have had for the past three years. This includes but is not limited to all current and past employers, banks, credit and depository institutions, accountants, brokers and credit bureaus. Date: Defendant's Mailing Address: Defendant's Date of Birth: Defendant's Signature: Street Address City State Zip Daytime Phone: Offense the Defendant is Convicted of Class A or Murder in Class B or Misdemeanor Unclassified the 1st or C Felony Felony 2nd Degree 500 200 1,500 1,000 500 250 250 250 2,500 1,500 1,000 500 500 5,000 2,500 2,000 750 750 Schedule of Costs for Court-Appointed Attorney [Criminal Rule 39(d)] Stage of the Case When the Case Ends Trial Misdemeanor change of plea Felony change of plea after substantive motion work and hearing but before trial starts Felony change of plea after indictment but before substantive motion work and hearing Felony change of plea before indictment Post-conviction relief or probation revocation proceeding in trial court For more information about the benefits and costs of a court-appointed attorney, go to www.courtrecords.alaska.gov/webdocs/forms/cr-204.pdf. CR-205 (3/16) (st.2) REQUEST FOR APPOINTED ATTORNEY AS 18.85 Crim. R. 39 & Admin. R. 12(e)(1) American LegalNet, Inc. www.FormsWorkFlow.com