IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT STATE OF ALASKA Plaintiff, vs. Defendant. ) ) ) ) ) ) ) ) ) ) ) CR CASE NO. REQUEST FOR APPOINTED COUNSEL I wish to have a lawyer and cannot afford to pay for one. I request that the court appoint a lawyer 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. Any financial information provided by me may be made available to the Attorney General after the conclusion of this case. If I give false information, the false information may be used to prosecute me for perjury under Alaska Statute 11.56.200. 3. If my financial situation changes and I do not report this to the court, the law requires my appointed attorney to do so. 4. If I am convicted, the court will enter a judgment against me which will require me to pay part of the cost of my appointed attorney. In most cases the court will use the schedule on the back of this form to determine the amount I will be required to pay. However, before the court decides, I will have a chance to ask the judge to order a lower amount. After the judgment is entered, I may request the court to reduce the amount of the judgment 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 City State ZIP Daytime Phone: Pamphlet CR-204 explaining the benefits and costs of court-appointed counsel is available from the court. CR-205 (8/07)(st.2)(front) REQUEST FOR APPOINTED COUNSEL AS 18.85 Crim. R. 39 & Admin. R. 12(e)(1) American LegalNet, Inc. www.FormsWorkFlow.com Schedule of Costs For Court-Appointed Counsel [from Criminal Rule 39(d)] Stage At Which The Case Ends Trial Offense of Which Defendant is Convicted Misdemeanor Class Class A or Murder in B or C Unclassified the 1st or Felony Felony 2nd Degree 500 1,500 2,500 5,000 Misdemeanor Change of Plea 200 Felony change of plea after substantive motion work and hearing but before trial begins 1,000 1,500 2,500 Felony change of plea after indictment but before substantive motion work and hearing 500 1,000 2,000 Felony change indictment 250 500 750 250 500 750 of plea before Post-conviction relief or probation revocation proceeding in trial court CR-205 (8/07)(st.2)(back) REQUEST FOR APPOINTED COUNSEL 250 American LegalNet, Inc. www.FormsWorkFlow.com