JIS CODE: WAA, RAA Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY WAIVER OF ATTORNEY OR REQUEST FOR APPOINTMENT OF ATTORNEY CASE NO. PETITION NO. Court address Court telephone no. 1. In the matter of name(s), alias(es), DOB WAIVER OF ATTORNEY 2. I am the respondent and I understand I have the right to be represented by an attorney at all hearings in the family division of the circuit court. If I cannot afford an attorney, the court will appoint an attorney to represent me. Knowing this, I freely waive the right to the assistance of an attorney. I am a juvenile and I understand I have the right to be represented by an attorney at all hearings in the family division of the circuit court. If I or the person responsible for my support cannot afford an attorney or refuses or neglects to retain an attorney for me, the court will appoint an attorney to represent me. Knowing this, I freely waive the right to the assistance of an attorney. Date Juvenile/Respondent signature 3. I, as parent, guardian, legal custodian, or guardian ad litem, agree with the above waiver of the assistance of an attorney. Date Parent/Guardian/Legal custodian/Guardian ad litem signature 4. I have explained the right to the assistance of an attorney as provided by law and court rule and am satisfied that the above waiver is voluntarily and understandingly made. I accept the waiver. Date Bar no. Judge/Referee REQUEST FOR APPOINTMENT OF ATTORNEY 5. I declare that I am unable to pay fully for the services of an attorney and request that an attorney be appointed by the court. I understand that I may be ordered to reimburse the court for all or part of the attorney fees and that when an attorney is appointed for a juvenile, that the court may assess some or all of the costs against the persons responsible for the support of the juvenile. I authorize the court to investigate and obtain relevant information from my employer, creditors, 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. Juvenile signature Date Parent/Guardian/Legal custodian/Respondent Name (type or print) Name (type or print) Address Date Address Telephone no. City, state and zip 6. Witnessed by: Telephone no. City, state and zip Date Name Do not write below this line - For court use only MCR 3.915, MCR 3.935(B)(4), MCR 3.942(B)(3), MCR 3.944(B)(4),(C)(1)(b), MCR 3.946(C)(2), MCR 3.951(A)(2)(b)(i), MCR 3.985(B)(3), MCR 3.987(C)(3) JC 06 (11/05) WAIVER OF ATTORNEY OR REQUEST FOR APPOINTMENT OF ATTORNEY American LegalNet, Inc. www.FormsWorkflow.com