IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT IN AND FOR ___________________ COUNTY, FLORIDA JUVENILE DIVISION In the Interest of ) ) ) ) ) Case No. a child APPLICATION FOR COUNSEL AND ORDER STATE OF FLORIDA COUNTY OF _______________________ Before me, the undersigned authority, personally appeared affiant, who, being duly sworn, says: 1. That I understand a delinquency complaint has been made against me and, being advised of my right to an attorney, now request appointment of counsel. 2. Being without sufficient funds, property or assets of any kind, I will be deprived of my right to representation unless I am adjudged insolvent and counsel appointed to represent me. 3. That I have been informed that a lien for the value of the legal services rendered to me by the public defender may be imposed by law on any property I now or may hereafter have in this state. Dated: ____________________________ _______________________________________ Affiant Child STATEMENT OF PARENTS The undersigned are informed and understand that liability for cost of representation of this child by the public defender can be assessed against the parent(s) by court order in an amount not to exceed the amount provided by law. _______________________________________ Parent _______________________________________ Parent ORDER The court finds that this child is indigent, as defined by law, and is desirous of counsel; it is, therefore, ORDERED 1. That this child is declared to be insolvent. Application For Counsel And Order {8.932} Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com 2. That , Public Defender for the Judicial Circuit, State of Florida, is hereby appointed as counsel to represent this child in all matters in defense of the delinquency complaint herein made. DONE AND ORDERED in the circuit court in and for on . County, Florida, _______________________________________ Circuit Judge Application For Counsel And Order {8.932} Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com