APPLICATION FOR APPOINTED DEFENSE SERVICES Child In Need of Care (CINC or JC) Juvenile Offender (JV) (TO ACCOMPANY A COMPLETED FINANCIAL AFFIDAVIT) IN THE MATTER OF: __________________________________ CASE NO. _______________ (Juvenile's name) NOTICE TO APPLICANT: A. General Information 1. The information on the attached affidavit is not confidential. 2. False entries may lead to criminal prosecution and conviction. 3. If you have any questions about answering any specific question, speak with the clerk. If you need help or do not understand a question, ask for assistance. 4. The judge may place you under oath and inquire futher about any information provided on this form. B. Eligibility for Attorney Services 1. Appointed counsel and other defense services will only be provided to people who cannot afford to pay for these services. 2. If the judge determines that you are able to pay a part of the cost of the services provided to you or your child, you will be found partially indigent and the court will order you to pay for a part of these costs. 3. You must inform the court if there is a change in any of the financial information given on the Financial Affidavit. Your obligation to keep the court informed of changes to your financial condition continues until your case is completely resolved. C. Repayment to the County 1. You may be required to reimburse the County for all or part of the expenses associated with the legal services provided to you or your child. 2. If, after the date of the alleged offense, you transfer any of your property for less than it is worth, the County may sue to obtain repayment of the cost of legal services provided to you or your child. I HAVE READ (OR HAVE HAD READ TO ME) AND UNDERSTAND THE ABOVE NOTICE. I hereby request that court-appointed counsel be provided to me/my child and agree to attempt to repay the County for the costs of my/my child’s legal representation if the court so orders. Date ____________________ _______________________________________ Signature of Applicant American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL AFFIDAVIT Please print clearly. You must show proof of identification to and sign this completed form in front of a Notary Public or a clerk of the District Court who will then verify it. ____________________________________________ Case No. ___________________ Juvenile's Name Parent(s)/Custodian Information: Last Name_____________________________ First Name _____________________ M.I. ___ Street Address_______________________________________________________________ City ______________________________ State ______________ Zip ___________________ Telephone No. _______________________________________________________________ Spouse (if married): Last Name______________________________ First Name_____________________M.I. ___ Street Address_______________________________________________________________ City ______________________________ State ______________ Zip ___________________ Telephone No. _______________________________________________________________ Parent Employment Information: Mother: Monthly Income $ ____________ Mother (check one): Employed Unemployed AFDC Social Security Mothers' Employer: _____________________________________________________ Employers' Address: ____________________________________________________ Dates of Employment: _____________________ Father: Monthly Income $______________ Father (check one): Employed Unemployed AFDC Social Security Fathers' Employer: ______________________________________________________ Employers' Address: ____________________________________________________ Dates of Employment: ______________________ Combined Monthly Incomes: $_________________ X (times) 12 months = $______________ Other Income: Within the last 12 months have you received any other income, including income from a business, rent payments, public assistance, support, or other sources? Yes No If Yes, give the amount received and identify the source of that income: Amount $________________ from _______________________________________________ Amount $________________ from _______________________________________________ Amount $________________ from _______________________________________________ Amount $________________ from _______________________________________________ Cash: Do you have any available cash or money in savings or checking accounts, certificates Yes No of deposit, or other funds? If Yes, what is the total combined value/how much is it worth? $________________ Property: Do you own a home, land, or other property? (Do not include ordinary household furnishings and clothing.) Yes No If Yes, what is the total value/how much is it worth? $_________________________ Financial Affidavit Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Dependents: Total number of dependents? _______________ List each dependents' name, age, relationship to you (son, daughter, father, mother, etc) and their marital status (single, married, widowed, divorced/separated). Dependent Name Age Relationship to You Dependent Marital Status _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ _______________________________ ___ ________________ _____________________ Debts/Monthly Expenses: How much to you spend per month on the following: a. Rent/House payment: $________________ b. Food/clothing/medicine: $________________ c. Utilities: $________________ d. Alimony/child support payments (paid by you): $________________ e. Installment payments: $________________ f. Other payments:____________________________$________________ Total monthly expenses (add lines a through f above): $________________ Statement of Parent(s)/Guardian: I can afford to pay $____________ to the Clerk of the District Court toward the court costs, attorney's fees, and witness fees. I, (print Parent/Guardian name)_____________________________________, of lawful age and under penalty of perjury, declare that I have read this affidavit, or that it has been read to me, about my financial condition, and taht the statements contained therein are true. ___________________________________________ Signature of Parent or Guardian Subscribed and sworn to before me this __________ day of _____________________, __________. My commission expires: _____________ __________________________________ Signature Notary Public or Clerk pursuant to K.S.A. 53-504 American LegalNet, Inc. www.FormsWorkFlow.com DETERMINATION OF ELIGIBILITY 2009 Poverty Guidelines for the 48 Contiguous States and the District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . Poverty Size of family unit Guideline 1..................................................................................$10,830 2..................................................................................$14,570 3..................................................................................$18,310 4..................................................................................$22,050 5..................................................................................$25,790 6..................................................................................$29,530 7..................................................................................$33,270 8..................................................................................$37,010 ................................................ For family units with more than 8 members, add $3,740 for each additional person. (The same increment applies to the smaller family sizes also, as can be seen in the figures above.) __________________________________________________________________________ JUDGE’S USE ONLY: Appointment Denied Public Defender Appointed Attorney Appointed: _________________________________ Partially Indigent, able to pay $_________________________ _______________________________________ Judge of the District Court American LegalNet, Inc. www.FormsWorkFlow.com