FOR CLERK’S USE ONLY FINANCIAL AFFIDAVIT For Court-Appointed Attorney, Expert or Other Services (K.A.R. 105-4-3) Judicial Dist. County CASE NO. FALSE STATEMENTS COULD RESULT IN ANOTHER CASE BEING FILED AGAINST YOU!! Name Birth Year Age Address Phone City S.S.# xxx-xxState Zip Code Spouse (If married – including common-law) 1. Are you Self-Employed Employed Unemployed If self-employed, what line of work? If employed, who do you work for? If unemployed, for how long? Are you receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 2. List the places you have worked in the last six months: 1. 2. 3. Name Name Name Address Address Address 3. If employed, give an approximate monthly rate of pay 4. Is your spouse Self-Employed Employed Unemployed If self-employed, what line of work? If employed, who does he/she work for? If employed, give an approximate monthly rate of pay If unemployed, for how long? Is he/she receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 5. Do you own a car, truck, or motorcycle? Yes No If yes, give year, make and model: 1. 2. Please give value 6. Is it paid for? Yes No Amount owing Do you receive, or have you received, in the past six months, income from rental property, public assistance, support, alimony, maintenance, or other sources, including from a business? Yes No If yes, give source and monthly income: 7. Do you have money or cash in savings, checking accounts or other funds? Yes No If yes, list amount of money available to you 8. Do you own a home, land, or other property? Yes No If yes, give value 9. Can you afford to pay anything toward the costs of your defense at this time? Yes No If yes, how much 10. Do you currently have any other court cases pending in the District, in which you already have counsel appointed? Yes No If yes, give attorney’s name Page 1 American LegalNet, Inc. www.FormsWorkflow.com (Check One) DEPENDANTS SINGLE MONTHLY BILLS TOTAL NUMBER RENT/HOUSE PAYMENT MARRIED LIST NAMES, AGES AND FOOD/CLOTHING WIDOWED RELATIONSHIP TO YOU UTILITIES SEPARATED/DIVORCED ALIMONY/MAINTENANCE CHILD SUPPORT INSTALLMENT PAYMENTS OTHER PAYMENTS TOTAL PAYMENTS I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorize the STATE OF KANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings, and any other asset balances that are needed to process this affidavit with the district court. I further authorize the STATE OF KANSAS to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references. Executed this day of , 20 . ____________________________________________________ Signature of Applicant FOR JUDGE’S USE ONLY DETERMINATION OF ELIGIBILITY – K.A.R. 105-4-1(b): “An eligible indigent defendant is a person whose combined household income and liquid assets equal less than the sum of the defendant’s reasonable and necessary living expenses plus the anticipated cost of private legal representation.” TO BE COLLECTED PURSUANT TO K.S.A. 22-4529: APPLICATION FEE OF $100 effective 7/1/04 Estimate of anticipated cost of private legal representation: Applicable poverty guideline level: APPOINTMENT DENIED PARTIALLY INDIGENT, ABLE TO PAY $ PUBLIC DEFENDER APPOINTED ATTORNEY APPOINTED Judge 2007 Poverty Guidelines for the 48 Contiguous States & the District of Columbia Size of Family Unit Poverty Guideline 1......................................................$ 10,210 2......................................................$ 13,690 3......................................................$ 17,170 4......................................................$ 20,650 5......................................................$ 24,130 For family units with more than 5 members, add $3,480 for each additional member. Revised 06/08/07 Page 2 American LegalNet, Inc. www.FormsWorkflow.com