IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA IN AND FOR THE FIFTH APPELLATE DISTRICT People of the State of California vs. __________________________ [Defendant/Appellant's NAME] Case No.: _________________ County:___________________ APPLICATION FOR APPOINTMENT OF COUNSEL I, __________________________[NAME], appellant in the above-entitled proceeding, now pending in the Court of Appeal of the State of California, Fifth Appellate District, do hereby request the court to appoint an attorney to represent me in this proceeding. In support of this request, I declare that I have no means of retaining an attorney to represent me; my present income and assets are: INCOME Husband Gross month income, including welfare, unemployment, etc. . . . . . . . . Less deductions: Income taxes. . . . . . . . . . . . . . . . . . . Social Security. . . . . . . . . . . . . . . . . . Unemployment insurance. . . . . . . .. . . . Medical Insurance. . . . . . . . . . . . . . . . Union dues, etc. . . . . . . . . . . . . . . . . . Retirement fund . . . . . . . . . . . . . . . . . Total Deductions. . . . . . . . . . . . . . . . . . . . . $ Net monthly income . . . . . . . . . . . . . . . . . . . $ Wife $ * $ * $ $ American LegalNet, Inc. www.USCourtForms.com Page 2 Case No. __________________ Husband Savings accounts . . . . . . . . . . . . . Checking accounts . . . . . . . . . . . . . Credit union . . . . . . . . . . . . . . . Bonds and stocks . . . . . . . . . . . . . Home . . . . . . . . . . . . . . . . . . . Other real estate . . . . . . . . . . . . . Furniture . . . . . . . . . . . . . . . . . Auto or truck . . . . . . . . . . . . . . . (make and year) Other vehicles . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . Total assets . . . . . . . . . . . . . . . Occupation: Employer: My monthly expenses are: Rent or mortgage . . . . . . . . . . Food . . . . . . . . . . . . . . . . Clothes . . . . . . . . . . . . . . . Transportation . . . . . . . . . . . Utilities . . . . . . . . . . . . . . Medical, dental . . . . . . . . . . . Child care . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . Installment payments: Creditor: $ $ $ Total monthly expenses: $ $ $ $ $ $ $ $ $ $ $ $ ASSETS Wife $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly payments $ $ $ Balance I declare under penalty of perjury that the foregoing is true and correct, and that this declaration was executed on at California. Type or print name Signature of declarant , Address of declarant American LegalNet, Inc. www.USCourtForms.com