One Hamilton County Square, Suite 215 Noblesville, Indiana 46060 Telephone (317) 770-4450 HAMILTON COUNTY SUPERIOR COURT 6 CAUSE NO. 29D06-______-____-__________ Please complete cause number for your case. AFFIDAVIT OF INDIGENCY AND REQUEST FOR APPOINTMENT OF COUNSEL Please state accurately and completely the following information: Name ____________________________________ Age _____ Telephone No. (_____) ______-_________ Date of Birth _____/_____/__________ Social Security Number (last four digits only) ____________ Street Address ___________________________________________________________________________ City_________________________________ State_____________________ Zip___________ Occupation ________________________ How often are you paid? ______________ Current Employer __________________________________ Amount you BRING HOME when you are paid $__________ Amount you are paid BEFORE DEDUCTIONS $__________ If you are unemployed, how long have you been unemployed? ________________ Why are you unemployed? __________________________________________________________________ Are you (check one): married? single? divorced? If are married, what is your spouse's name? __________________________________ Please list spouse's address, if different from yours: Street Address ____________________________________________________________________________ City_________________________________ State_____________________ Zip___________ Spouse's Occupation ____________________ Spouse's Employer _________________________________ How often is your spouse paid? ____________ Amount spouse BRINGS HOME when paid $____________ Amount spouse paid BEFORE DEDUCTIONS $___________ If your spouse is unemployed, how long has he or she been unemployed? ________________ Why is your spouse unemployed? _____________________________________________________________ For BOTH you and your spouse, if married, please list all other sources of income: Unemployment Severance Pay Disability Worker's Comp. Child Support Sick Pay Welfare Other How much?_________ How much?_________ How much?_________ How much?_________ How much?_________ How much?_________ How much?_________ How much?_________ How often received? ___________________ How often received? ___________________ How often received? ___________________ How often received? ___________________ How often received? ___________________ How often received? ___________________ How often received? ___________________ How often received? ___________________ Is your health good? ______ If not, please explain?______________________________________________ Page1 American LegalNet, Inc. www.FormsWorkFlow.com Who else lives with you in your residence? NAME ________________________ ________________________ ________________________ ________________________ AGE _____ _____ _____ _____ OCCUPATION WEEKLY INCOME ______________________________________ $_______________ ______________________________________ $_______________ ______________________________________ $_______________ ______________________________________ $_______________ Do you own real estate? _____ If yes, its value $____________ Amount owed on it, if any $______________ Do you pay rent? _____ If yes, total amount of rent $___________ Amount that you pay $_______________ Do you pay child support? _______ If yes, how much do you pay each month $_________ Arrears: $________ Please list all vehicles, such as car, trucks, or motorcycles, that you own or that are in your name:: Type of Vehicle_________________________ Value $__________ Amount owed on it, if any $__________ Type of Vehicle_________________________ Value $__________ Amount owed on it, if any $__________ Please list all other property that you own, such as boats, televisions, trailers, etc., worth $500 or more: Type of Property________________________ Value $__________ Amount owed on it, if any $__________ Type of Property________________________ Value $__________ Amount owed on it, if any $__________ Please list all debts that you owe over $250: WHO DO YOU OWE? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ AMOUNT YOU OWE? $_____________________ $_____________________ $_____________________ $_____________________ Please list all bank accounts in you name individually or jointly with somebody else: Type of account ___________________________ Type of account ___________________________ Amount in account $____________ Amount in account $____________ Why do you need an attorney? _______________________________________________________ If you have another case pending under a different cause number, please list the attorney who is representing you on the other case: ________________________________________ If you are charged with a violation of probation, please list the attorney who represented you on this case when pled guilty, or who represented you on a prior violation this case: ____________________________________ I understand that I may be ordered by the Court to reimburse the County in part or in whole for the public defender services if the Court does appoint a public defender for me. Under the pains and penalties for perjury, I hereby solemnly swear, or affirm, that the information above is true and correct to the best of my knowledge, information and belief. Date: _____________________ Signature: __________________________________________ Page2 American LegalNet, Inc. www.FormsWorkFlow.com