CR-JV-032, Rev. 01/18 Page 1 of 1 Unified Criminal Docket STATE OF MAINE County: Superior Court Location: District Court Docket No.: STATE OF MAINE/ vs. MOTION AND AFFIDAVIT FOR ASSIGNMENT OF COUNSEL Defendant/Juvenile I am requesting the Court to assign an attorney at public expense, based on the following accurate information. Name of person whose financial information appears on this affidavit: Single Married Divorced Widowed Mailing address (if PO Box, also list physical address): Date of Birth: Telephone number (working with voice mail) Message number I live Alone. I live with Spouse/Significant Other Parents Friends other I have: children Age(s): who live me for whom I pay child support of $ per . I am current on my child support: Yes No INCOME: Salary / Gross Income: $ per Year Month Week or hourly wage $ and number of hours I receive: Social Security $ Unemployment $ TANF $ Alimony/ Child Support $ Food Stamps $ Maine Care/Housing/WIC Employer: how long have you worked here? If unemployed, last date employed: Place of employment: Taxes: Last filed: Refund paid to me Refund taken by State of Maine ASSETS: Cash bail posted (1st party) in this case or any other case $ Cash on hand or at home $ Cash in the bank $ Money owed to you $ Name of bank/FCU : Stocks/Bonds/401K/403B/Pensions: Property worth more than $250 (include property owned alone or with other people): Home and land $ Amount owed on property $ Vehicle(s) YR/Make Model Amount Financed $ Recreational Vehicle(s)/ ATV/boat/snowmobile (YR/make /model): Other (personal-TV/computer/electronics etc): EXPENSES: (Monthly) Mortgage/Rent Cable/Internet Loan (student) Atty. Fees Food Heat Loan (personal) RX Cell Phone Car Insurance Prop. Taxes Other Utilities Credit Card Court fees/Fines Other Renter/home Owners insurance Total Expenses: $ I acknowledge that disclosure of my Social Security account number is mandatory under 36 M.R.S. 2445276-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 assigned to represent me if it is later determined that I am to be responsible for all or part of the attorney fees and costs. The undersigned furnishes the above information to support the request for assignment of counsel. 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. 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. I also understand that further investigation may be conducted to verify the information I have provided, and I agree, as a condition of my continued eligibility to be represented by assigned counsel, to cooperate with any such investigation, including providing documents or authorizations to release information requested by the court or by the Maine Commission on Indigent Legal Services. Date: Signature of Applicant Subscribed and sworn to before me, Notary, Clerk, Attorney, Judge/Justice Financial Screener325s Recommendation: ! American LegalNet, Inc. www.FormsWorkFlow.com