8 Rule 8.33 — Form 3 February 2002 IN THE IOWA DISTRICT COURT FOR ________________________ COUNTY IN THE INTERESTS OF ____________________________________, A Child. No. ______________________________ APPLICATION FOR APPOINTMENT OF COUNSEL AND FINANCIAL STATEMENT (Juvenile Proceedings) I, __________________________________________________, state that I am the (parent) (guardian) (custodian) of ____________________________________________________, a child, and request that the court appoint counsel to represent (me) (the child) 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): _______________________________________________ Martial 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 banking 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): ________________ _____________________________________________________________________________________________ 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: $ __________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Are you a beneficiary or heir in an estate of a person deceased? ___________________________________________ List all debts or unpaid bills, including money owned 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 (you) (the child) 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) (the child) because I am financially unable to employ counsel. __________________________________________________ _____________________________________________________________________________________________ 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