Rule 1.1901 — Form 8 February 2002 IN THE IOWA DISTRICT COURT FOR _______________________ COUNTY Plaintiff, No. ______________________________ v. APPLICATION FOR APPOINTMENT OF COUNSEL AND FINANCIAL STATEMENT Defendant. (General) I request that the court appoint counsel to represent me at public expense. I realize that I may be required to repay in whole or in part any public funds expended for this purpose. The following financial statement is submitted in support of my application: Current mailing address: _________________________________________________________________________ Age: _______________________________ Telephone number(s): _______________________________________ Marital status: Single _____________ Married __________ Divorced ____________ Widow(er) _______________ Name of husband/wife: ___________________________________ Live with husband/wife Yes ______ No ______ If no, length of physical separation from husband/wife: _________________________________________________ Number and ages of dependents: ___________________________________________________________________ _____________________________________________________________________________________________ How long a resident of this county: _________________________________________________________________ Occupation: ___________________________________________________________________________________ Present employer: ______________________________________________________________________________ Address: _____________________________________________________________________________________ Former employer: ______________________________________________________________________________ Address: _____________________________________________________________________________________ Weekly take-home (net) earnings: $ ______________________ Weekly gross earnings $ ______________________ Total gross income for past 12 months: $ _____________________________________________________________ Bank with: _________________________________________ Address: __________________________________ Balance personal bank account: $ ___________________________ Balance account in name of husband/wife: $ ___________________________ Balance joint account with husband/wife: $ ___________________________ Balance joint account with any other person(s): $ ___________________________ What is your average monthly living expense (clothing, food, housing, transportation, other)? $ _________________ Does any person pay all or any portion of these expenses: Yes _____ No _____ If yes, who pays these costs and how much do they contribute? ________________________________________________________________________ Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whether registered or titled in your name, name of husband/wife or jointly with another: __________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ List all sources of income, in your name, name of husband/wife or jointly shared with another, including salary (net wages), pensions, bonds, stocks, securities, private business, farming, insurance, retirement benefits, social security benefits, lawsuits or settlements or others: _________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ADC or welfare relief, if any, in your name, name of husband/wife or jointly shared with another: ________________ _____________________________________________________________________________________________ List all sources of public assistance, if any, including ADC, unemployment compensation, heating assistance, food stamps: ____________________________________________________________________________________ _____________________________________________________________________________________________ Real estate owned in your name, name of husband/wife or jointly shared with another (describe): ________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 8 Other assets in your name, name of husband/wife or jointly shared with another (stereo, TV, furniture, trust funds, notes, bonds, stocks savings certificates, life insurance, other): _____________________________________________________________________________________________ _____________________________________________________________________________________________ ___________________________________________ Value: $ ___________________________________________ Are you a beneficiary or heir in an estate of a person deceased? ___________________________________________ List all debts or unpaid bills, including money owed for such things as: Housing, food, clothing, transportation (car, gas), utility costs, medical and dental services and other items, be specific: __________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Does anyone owe you money or have any property belonging to you? _____________________________________ _____________________________________________________________________________________________ Give details in full: _____________________________________________________________________________ _____________________________________________________________________________________________ Do you have a judgment against anyone: Yes __________ No _________ If yes, give name, date, court and amount: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you or anyone else employed or offered to employ an attorney for _____________________________________ in this matter? Yes ___________ No ___________ If so, how much has the attorney been paid by you or for you? $ ____________________________________________________________________________________________ Who can verify this information: ___________________________________________________________________ Telephone number: ____________________ Address: ________________________________________________ I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the foregoing statements are true and correct to the best of my knowledge, and are made in support of my request that the court appoint legal counsel for me because I am financially unable to employ counsel. _________________________________________________________ (Signature of applicant) _____________________________________________________________________________________________ The State of Iowa: _________________ does not object to the appointment of counsel. _________________ objects to the appointment of counsel and requests a hearing on the application. Dated: _____________________________, 20 ______ . (Assistant __________________________________ County Attorney) American LegalNet, Inc. www.FormsWorkflow.com