APPLICATION FOR APPOINTED DEFENSE SERVICES (to accompany Financial Affidavit) STATE vs. District Court Case No. County Douglas 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 FOR CLERK’S USE ONLY FINANCIAL AFFIDAVIT D. 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 Age Birth Year Phone S.S.# xxx-xxCity Address State 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 American LegalNet, Inc. www.FormsWorkflow.com 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 (Check One) DEPENDANTS TOTAL NUMBER SINGLE MONTHLY BILLS 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 , 20 . of ____________________________________________________ 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com