Approved, SCAO JIS CODE: RFC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY REQUEST AND ORDER FOR COURT APPOINTED APPELLATE COUNSEL CASE NO. PETITION NO. Court address Court telephone no. 1. In the matter of name(s), alias(es), DOB REQUEST 2. I, , declare my intent to appeal from the order entered on Name in the Date Court by Hon. Bar no. . 3. I understand I have the right to be represented by an attorney. I am unable to pay fully for the services of an attorney and for the cost of transcripts and have completed the Financial Schedule on the other side of this form. 4. I request an attorney be appointed by the court and the cost of transcripts be waived. I understand I may be ordered to reimburse the court for all or part of the attorney fees and transcript costs. 5. I authorize the court to investigate and obtain any further relevant information from my employer, creditors, the Department of Human Services, the Social Security Administration, and others who have knowledge of my financial circumstances for purposes of aiding the court in determining my eligibility for the appointment of an attorney and waiver of costs of transcripts. Date Signature Address Name (please print) City, state, and zip Telephone no. ORDER IT IS ORDERED: 6. The request for appointed counsel is denied because 7. is appointed to represent the requesting party to conduct an appeal. The court reserves the right to order reimbursement for attorney fees and transcript costs. 8. , court reporter/recorder, R number , shall furnish the transcript required by counsel for these appellate proceedings and the reporter/recorder shall be compensated for the transcripts as provided by law. 9. IT IS FURTHER ORDERED: Date Judge Bar no. Do not write below this line - For court use only USE NOTE: This form is not to be used for requests and orders for appellate counsel after termination of parental rights. See form JC 84. JC 81 (11/05) REQUEST AND ORDER FOR COURT APPOINTED APPELLATE COUNSEL MCR 3.915(B) American LegalNet, Inc. www.FormsWorkflow.com Complete this Financial Schedule if you are seeking a court-appointed attorney. FINANCIAL SCHEDULE 1. RESIDENCE Rent Own Live with parents Room/Board Married Divorced Separated 2. MARITAL STATUS Single 3. INCOME a. Employer name and address Dependents: Number b. Length of employment c. Average of pay weekly Gross: $ monthly Net: $ every two weeks d. Other income State monthly amount and source, such as DHS, VA, rent, pensions, spouse, unemployment, child support, etc. 4. ASSETS State value of car, home, bank deposits, bonds, stocks, etc. 5. OBLIGATIONS Itemize monthly rent, installment payments, mortgage payments, child support, etc. 6. REIMBURSEMENT I understand that I may be ordered to reimburse the court for all or part of my attorney and defense costs. I declare under penalty of contempt of court that the above information is true to the best of my information, knowledge, and belief. Date Signature American LegalNet, Inc. www.FormsWorkflow.com