APPLICATION FOR APPOINTED DEFENSE SERVICES (to accompany Financial Affidavit) STATE vs. District Court Case No. County NOTICE TO APPLICANT: A. General Information 1. 2. The judge or the Kansas Board of Indigents’ Defense Services may verify any information contained on the attached affidavit. 3. False entries may lead to criminal prosecution and conviction. 4. If you do not understand a specific question or need help, ask for assistance. 5. B. The information on the attached affidavit is not confidential. The judge may place you under oath and inquire further about any information provided on this form. Eligibility for Defense Services 1. 2. If the judge determines that you are able to pay a part of the costs of your defense, you will be found partially indigent and the court will order you to pay for a part of these costs. 3. If, after the date of the alleged offense, you transfer any of your property for less than it is worth, the State may sue to obtain repayment of the cost of your defense. 4. C. You will receive an appointed attorney if you meet the standards for indigent status. You must inform the court if there is a change in any of the financial information given on the affidavit. Repayment to the State The court shall take into account the financial resources and the nature of the burden that payment of such sum will impose. Any person who has been required to pay such sum and who is not willfully in default may petition the sentencing court to waive payment of any remaining balance or portion thereof. I have read or have had read to me and understand the above notice. I hereby request that courtappointed counsel be provided to me and agree to attempt to repay the State for the costs of my defense if the court so orders. Date Defendant Revised 06/02/06 American LegalNet, Inc. www.FormsWorkflow.com