IN THE CIRCUIT COURT OF SEBASTIAN COUNTY, ARKANSAS Fort Smith/Greenwood District State of Arkansas vs. ______________________ Certificate of Indigency Now comes the Defendant in the above cause and certifies under penalty of perjury that he/she is indigent and unable to hire private counsel to represent them on the above charge and desires the court to appoint the Public Defender to represent the Defendant and in support of said motion states as follows: 1. My current employment is: 2. My average take home salary is: 3. My assets in saving/checking is: 4. I made a bond in the amount of: 5. My dependents are: 6. Other Information: _____________________________ Length_________ $________ Per _____ Other Income ____ Per _______ $________ Other Assets:________________________ $___________ With:___________________________ ____________________________________________ ____________________________________________ CR. __________________ Defendant Plaintiff The Defendant understands that the failure to answer the above questions truthfully can result in a charge of Perjury and if convicted a term of imprisonment in the Arkansas Department of Corrections for a period of not more than six years. Date:___________________ Phone:__________________ Signature:______________________________________ Address:_______________________________________ ORDER Now on the Motion of the Defendant and in consideration of the facts set forth in the Certificate of Indigency: IT IS THEREFORE ORDERED that the Public Defender is hereby appointed to represent the Defendant on the above charge. IT IS FURTHER ORDERED that the Defendant is assessed to pay the sum of $100 pursuant to Arkansas Code 16-87-213 to be paid to the Prosecuting Attorney's Office, upon the plea or the conviction of the defendant, to be forwarded to the Public Defender User Fee Fund. ____________________________________ Circuit Judge American LegalNet, Inc. www.USCourtForms.com