SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY JUVENILE COURTCASE #: JD _______________ REQUEST FOR REVIEW HEARING/ F# _______________ APPOINTMENT OF ATTORNEY/ AND/OR INTERPRETERNAME(S) OF CHILD(REN): ________________________________________________________________________last first middle date of birthlast first middle date of birth________________________________________________________________________last first middle date of birthI am the ___ mother ___ father ___ guardian. My name is:________________________________________________________________________last first middle social security #________________________________________________________________________address city state zip codehome phone number work phone number message phone numberI want (check all that apply): _____ a hearing within 5 court days to review temporary custody._____ an interpreter to assist me at court hearings._____ a court-appointed attorney. If requesting a court-appointed attorney, you must also complete a Financial Affidavit to Determine Eligibility for a Court-Appointed Attorney.signature dateForm 602 Clerk of Superior Court of Arizona in Maricopa CountyAugust 20, 1999 ALL RIGHTS RESERVED >>>> 2 SUPERIOR COURT OF ARIZONA IN MARICOPA -- JUVENILE COURT In the Matter of ) Case No. ) PARENTS FINANCIAL AFFIDAVIT TO DETERMINE ________________________________ ) ELIGIBILITY FOR A COURT-APPOINTED ATTORNEY INSTRUCTIONS: Complete this form with information about your financial circumstances, so the Court can decide if you can affordto pay an attorney in your court case, or if an attorney should be appointed for you by the Court. If the Court appoints an attorneyyou might be ordered to pay some of the costs of the lawyer. You may also hire your own lawyer at your own expense, but youmust do so BEFORE the Court Conference and Hearing date indicated on the Notice from the Court. BRING THIS FORM WITH YOUTO COURT GENERAL INFORMATION: 1. Your Name: _______________________________________________Daytime Phone Number ________________ Message Phone Number_________________2. Your Relationship to Children: o Mother o Father o Other (explain) ___________________________ 3. Relationship to the Other Parent:o Now Marriedo Divorced o Never Married o Other (explain) ___________________________ 4. How much can you afford to pay monthly for lawyer fees? $______________ INCOME: 1. Are you now receiving welfare (TANF), low income disability assistance (SSI) o YES o NO (If YES, bring papers to court proving the type of help you get; do not complete this form any further.)2. Gross monthly income, from employment, without any deductions: $________________ Name and address of employer:_______________________________________ 3. Monthly amount received from child support and/or spousal support (alimony) $________________ Name of person who pays this :________________________________________ 4. Monthly amount received from social security or other government benefits: $________________ Source of government benefits (social security, etc.) _______________________ 5. Other monthly amount received from any source : $________________ Source of the income (pensions, trusts, etc..) _______________________________ ASSETS: 1. Total fair market value of all assets: $_________________ Car: $_________ House (if you own) $___________ Other valuables $___________ Explain: _____________________________________ 2. Cash on hand or available to you now: $_______________ SUPPORT OBLIGATIONS: 1. Amount of child support and/or spousal support you pay monthly $_________________ Name of person you pay: _________________________________ 2. How many persons live in your household that you are supporting?_____________ 3. How many other persons are you supporting? _____________ HOUSEHOLD EXPENSES 1. Monthly cost for rent or mortgage and utilities: $_____________2. Monthly cost of car payments and insurance: $_____________3. Other monthly expenses (total) $_____________ a. Payable to whom, and amount? _______________________________ b. Payable to whom, and amount? ______________________________ I affirm under penalty of perjury that I have completed this Financial Affidavit, and I have truthfully and completely providedinformation about my financial resources. I understand that the Court may require me to provide further details about my financialcircumstances in order to assess my ability to pay for costs of attorney services. Signature: _______________________________________ Date: ____________________________Name Printed: _______________________________________ Address:_________________________