U Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS Chapter 31 RT OF JUS TI C E AOC-350 Rev. 5-16 Page 1 of 3 Doc. Code: AI & 0I COM M O CO NW E A LT H O F K E lex et justitia Case No. ____________________ Court County Division ____________________ ____________________ ____________________ Age: _______ FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, REQUEST FOR COUNSEL AND ORDER (CRIMINAL CASES) Name: ____________________________________________________________ () Telephone: __________________________ Address:__________________________________________________________________________________________ Charges: _______________________________________________________________________________________ _______________________________________________________________________________________________ FINANCIAL STATEMENT: 1. Income: Employed? If Yes: q Yes q Full-time q monthly Married? q Yes q No q Part-time q biweekly q No q Temporary/Seasonal Length of Employment: ___________ q hourly $_______________ If Yes, Spouse Employed? q monthly q biweekly q Yes q No NT U C KY Income from Employment: If No, date last employed: _____________________________ If Yes, Spouse's Income from Employment: q Welfare: $__________ q hourly $________________ Total Income from ALL other source(s) and amount received per month: q Food Stamps:$ ___________ q Social Security/Disability:$____________ q Retirement:$____________ q Worker's Comp: $__________ q Unemployment:$____________ q Child Support/Maintenance: $___________ q Child Care Assistance: $______________ q Stocks, Trusts, Bonds:$________________ q Other : _____________________________________________ Total Income from ALL other source(s): $ _______________________ TOTAL MONTHLY INCOME: 2. Property: Own Real Estate? Own Mobile Home? Own Personal Property: Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.): Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Bank Accounts: q Yes q No If Yes, total balance of all accounts: $________________________ Other Asset(s) (i.e., boat, jewelry, cash) Asset type: _________________ Value: $ _________________ Amount owed: $_______________ Asset type: _________________ Value: $ _________________ Amount owed: $_______________ American LegalNet, Inc. www.FormsWorkFlow.com $ _______________________ q Yes q Yes q No $_________________ q No $_________________ Amount owed : $_______________ Amount owed : $_______________ If Yes, Value of Real Estate: If Yes, Value of Mobile Home: AOC-350 Rev. 5-16 Page 2 of 3 Doc. Code: AI & 0I 3. Dependents: q Yes q No Age(s) of Dependent(s)______________________ If Yes, Number of Dependent(s) (including children, elderly, or disabled): _____________ Relationship of dependent(s):_____________________ 4. Monthly Expenditures: Mortgage payment/ Rent: q Yes Child support obligation: q Yes q No q No If Yes, amount of payment: $_________________________________ If Yes, amount of payment: $_________________________________ Other out-of-pocket monthly bills (FOR HOUSEHOLD): q utilities: $___________ q water: $ ___________ q telephone service (land or cell): $ ___________ q car payment: $_____________ q medical debts: $___________ q internet service: $___________ q credit card payments: $___________ q unreimbursed childcare: $___________ q cable/satellite: $___________ q tuition: $___________ q car / health/home owners/ renters insurance payments: $__________ q student loan payments: $___________ q Other Financial Obligations: $ _______________________________ Total of other out-of-pocket monthly bills:$______________________________ TOTAL MONTHLY EXPENDITURES: 5. Cash bond posted: q Yes q No If Yes, amount of bond: $___________________________ Posted by (Name of Surety): _____________________________________________________ Request for Appointment of Counsel: I state to the Court that: (1) I am not now represented by an attorney and (2) I am without sufficient financial means or assets to afford a private attorney; or (3) I have retained or intend to retain private counsel. ____________________________________________________ Name of Counsel $______________________________ PERJURY WARNING: I understand that making a false statement in the Financial Statement, Affidavit of Indigency, Request for Counsel and Order may subject me to the penalties for perjury as contained in KRS Chapter 523. The maximum sentence for perjury is five (5) years imprisonment. I declare under the penalty of perjury that I have read or have had read to me the information contained on this form and that the statements provided here are true, complete and accurate to the best of my personal knowledge. __________________________________, 2_____ Date ____________________________________________ Affiant's Signature __________________________________, 2_____ Date ____________________________________________ Signature/Title of Officer Administering Oath American LegalNet, Inc. www.FormsWorkFlow.com U Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS Chapter 31 RT OF JUS TI C E AOC-350 Rev. 5-16 Page 3 of 3 Doc. Code: AI & 0I COM M O CO NW E A LT H O F K E lex et justitia Case No. ____________________ Court County Division ____________________ ____________________ ____________________ FINANCIAL STATEMENT; AFFIDAVIT OF INDIGENCY; REQUEST FOR COUNSEL; AND ORDER (CRIMINAL CASES) ORDER Based upon the above attested statements, IT IS HEREBY ORDERED: 1. The Affiant, _________________________________________________________________________, q is NOT indigent pursuant to KRS Chapter 31 and the Request for Appointment of Counsel is DENIED. q is indigent pursuant to KRS Chapter 31 and the Request for Appointment of Counsel is GRANTED. The Court appoints the Department of Public Advocacy to represent the Defendant in the above-styled case. 2. A partial fee for representation q is NOT assessed. q is assessed in the amount of $ _________________ to be paid in full no later than the ____________ day of ____________________________, 2________. q may be reserved for a later date. NT U C KY ____________________________, 2_______ Date ____________________________________________ JUDGE ____________________________________________ District/Circuit (Circle one) Division ________ American LegalNet, Inc.