STATE OF MAINE INDIGENCY AFFIDAVIT SUPERIOR COURT DISTRICT COURT Location Docket No. , ss Docket No. PLEASE FILL OUT THIS FORM AS COMPLETELY AS POSSIBLE. Name Address Date of Birth Age court appointed lawyer for criminal case protective custody case waiver of fees and charges in the following civil case: single married divorced separated widowed Marital Status: I live: alone with spouse with parent with children with friend(s) List the names, ages and relationships of any dependents you support: Phone # I am requesting a other (list who) CASH ASSETS: AVAILABLE MONEY (List all money currently available; include joint as well as individual accounts.) a. Cash on hand $ b. Checking Account(s) $ Name of Financial Institution: c. Savings Account(s) $ Name of Financial Institution: d. Stocks, bonds, trusts, certificates of deposit, IRA, etc. $ Description: (value) e. Cash posted as bail $ f. Other (Christmas Club, etc.) $ Description: TOTAL CASH ASSETS: $ INCOME: 1. EMPLOYMENT (list employer name, address and telephone number) a. Where do you work? b. Length of time employed: Full Time Part Time Seasonal c. If not currently employed, where and when were you last employed? d. Do you anticipate other employment or other income within the near future? yes no If yes, please explain: 2. Do you receive any pay or any other kind of compensation for any other work you do that is not included above? If so, please explain: 3. MONTHLY/WEEKLY INCOME a. Salary and wages (take home pay) $ (per week month) b. Unemployment $ (per week month) (per week month) c. Social Security $ d. AFDC payments $ (per week month) (per week month) e. Alimony/child support $ f. Any income received and not reported above $ (per week month) (E.g., veteran's benefits, worker's comp., pensions/retirement, nat'l guard, room rental. Please specify) 4. ASSETS OF SPOUSE (Include roommate with whom you share expenses; if you are under 18 years old include your parent.) b. Relationship to you a. Name of Person c. Address d. No. of this person's dependants e. Is this person employed yes no If yes, where? f. Estimated monthly/weekly income? $ (per week month) g. Is any of this income available to you/used for you? If so, how much? (per week month) 5. Does anyone owe you any money? yes no If yes, how much? 6. Have you, or has anyone in your household, received or do you expect to receive, any payments such as retroactive government benefits, tax refunds, pay raises, law suit settlements, etc? If yes, please explain. CR-032, Rev. 11/96 (PLEASE COMPLETE REVERSE SIDE) 2000 © American LegalNet, Inc. OTHER ASSETS: Property (owned individually or with others) a. Do you own a house or other real estate? yes no If yes, what is the estimated market value of the property? $ What is the amount of any mortgage on the property? $ Who holds the mortgage? b. List make, model, year and value of all motor vehicles you have (automobiles, trucks, RV's, motorcycles, ATV's, snowmobiles, etc.) $ Who holds the title to these vehicles? Who are the vehicles registered to? c. List any other personal property (such as TV, stereo, VCR, valuable jewelry, antiques, etc.) having a value of $50.00 or more. d. Cash value of insurance policies, pension, retirement or profit sharing, etc. (Specify) EXPENSES: 1. Monthly Living Expenses a. Food and other grocery items $ b. Housing (rent/mortgage) $ c. Utilities (e.g. electricity, heat, water, sewer, telephone $ d. Other (Specify) TOTAL $ $ 2. Describe any loan payments or any other payments you make on a regular basis which are not normal living expenses. Lending Institution Purpose Total Amount Owed Monthly Payment $ $ $ $ $ $ TOTALS $ $ 3. Describe any regular payments you make for medical care, alimony/child support, child care, etc. (specify) TOTAL $ 4. Is there any other statement you wish to make about your financial condition that may be helpful in evaluating if you qualify for court appointed legal assistance? I acknowledge that disclosure of my Social Security account number on this form is mandatory under 36 M.R.S.A. §5276-A. My Social Security account number may be used to facilitate the collection of money that I may owe the State of Maine as a result of having had an attorney appointed to represent me if it is later determined that I am to be responsible for all or part of the attorney fees and costs. My Social Security account number is . I furnish the above information to support my request for appointment of counsel to represent me with regard to the pending charges. I have read the above form, I understand it, and the answers to the questions are true. I understand that any false answers on this form may subject me to criminal prosecution, and that a court investigator may seek to verify my statements. I also understand that I have a continuing obligation, personally and through counsel, to report to the court any changes in my employment or other financial circumstances. Date: Signature of party Subscribed and sworn to before me, Attorney - Clerk of Court - Notary Public - Judge / Justice Based on review of defendant's financial circumstances, including an interview of the party, I make the following recommendation: ELIGIBLE NOT ELIGIBLE PARTIALLY ELIGIBLE $ RECOMMENDATION _