en-USIN THE INTEREST OF: , A CHILDen-USI en-USAMen-US A en-US(check one):en-US en-USen-US parent who exercises custodial control or supervision of the above-named child in a dependency, neglect or abuse action;en-USen-US person (not a parent) who exercises custodial control or supervision of the above-named child in a dependency, neglecten-USor abuse action;en-USen-US person (not a parent) claiming to be a de facto custodian of the above-named child in a dependency, neglect or abuse en-USaction;en-USen-US parent of the above-named child in a termination of parental rights action; oren-USen-US biological parent of the above-named child who does not consent in an adoption action.en-USAND HEREBY PROVIDE THE FOLLOWING INFORMATION: en-USNAME: en-USADDRESS: en-USen-USen-USSSN: DOB: Telephone: en-USen-US en-USThe above-named parent is an unemancipated minor (under the age of 18) and I am his/her en-USparent or legalen-USguardian .en-USFINANCIAL STATEMENT: (Complete the following information. NOTE: If the child222s parent is an unen-USemancipated en-USminor, the adult parent or legal guardian of the unemancipated minor should provide the information) en-USAOC-DNA-11 Doc. Code: AICOen-USRev. 7-18en-USPage 1 of 2en-USCommonwealth of Kentuckyen-USCourt of Justice en-USwww.courts.ky.goven-USKRS Chapter 31; KRS 199.502en-USKRS 620.100; 625.0405; 625.060;en-US625.080; FCRPP 17en-USen-USRequest for Counsel and Orderen-US(DNA/TPR/ADOPTION Cases) lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE 1. en-US Are you employed? en-USen-US Yes en-USen-US Noen-US2.en-US If 223Yes,224 are you en-USen-US Full time; en-USen-US Part time; or en-USen-US Seasonal/Temporary en-US3.en-US How many adults are living in your household? en-US4.en-US How many children are living in your household? en-US5. Total Household Income Per Month: þ $ en-US6. Available Cash from ALL SOURCES (bank accts, TANF, SSI, SSD, W/C, etc.) þ $ en-US7. Cash value of other resources (food stamps, WIC, etc.) þ $ en-US9.en-US Property Ownership: en-USen-US Yes en-US No þ Property Value: þ $ en-US10. Number of autos you own that are in working order: Total Value: þ $ en-US11. Total Value of All Other Assets: þ $ en-US12. Total Debts: þ $ en-US13.en-US Child support obligation? en-USen-US Yes en-US No þ Monthly Total: þ $ en-US14.en-US Other obligations en-US15.en-US Number of dependents: en-USREQUEST FOR THE APPOINTMENT OF LEGAL COUNSEL:en-USI state to the court that: en-US(1) I am not now represented by legal counsel; and en-USen-US(mm/dd/yyyy) en-USArea code + numberen-US(Name of Parent or Legal Guardian of Minor Parent)en-USCase No. en-USCourt en-USen-US District en-USen-US Family en-USCounty en-USDivision American LegalNet, Inc. www.FormsWorkFlow.com en-USAFFIDAVIT OF INDIGENCEen-USPERJURY WARNING þ en-USen-USest for en-USAppointment of Counsel may subject me to the penalties for perjury as contained in KRS Chapter 523. en-USThe maximum en-USen-US I declare under the penalty of perjury that I have read or have had en-USread to me the information contained on this form and that the statements provided here are true, complete and accurate en-USto the best of my personal knowledge. þ en-US þ þ þ en-US(print or type) en-USORDERen-USBased on this application/motion, en-USIT IS HEREBY ORDERED: en-US1. The applicant, or legal guardian/parent of the applicant: en-USen-US is NOT deemed indigent under KRS Chapter 31.en-USen-US IS founden-US to be inen-USdigent under KRS Chapter 31.en-US2. en-USAPPOINTMENT OF COUNSELen-USen-US is en-USDENIEDen-US.en-USen-US is en-USGRAen-USNTen-USEDen-US.en-USen-US en-USen-USoren-US that the applicant is a party to aen-UStermination of parental rights en-USoren-US an adoption proceeding, en-USDOES HEREBY APPOINTen-US the Hon. en-USen-USFinance and Administration Cabinet pursuant to KRS 620.100, 625.080, or 199.502. þ þ þ þ en-US(print or type) en-USSUBSCRIBED AND SWORN TO before me this day of , 2en-US. My Commission Expires: þ þ en-USDistribution: en-USen-US Court Fileen-USen-US Applicanten-USen-US Appointed Counselen-USAOC-DNA-11 Rev. 7-18þ Case No. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com