APPENDIX 1 COURT-APPOINTED COUNSEL REQUEST FORM 12TH JUDICIAL DISTRICT NAME: ______________________________________________________________________ ADDRESS: ______________________________________________________________________ OFFICE PH: ______________________________________________________________________ MOBILE PH: ______________________________________________________________________ EMAIL: ______________________________________________________________________ NE BAR NO: ______________________________________________________________________ I request to be considered for court appointments for indigent defendants in the following counties in the 12th District: 1. ____________________________________ 2. ____________________________________ 3. ____________________________________ 4. ____________________________________ 5. ____________________________________ 6. ____________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com I wish to be placed on the (__) misdemeanor list, (__) felony list, (__) both. Please initial: (__) I am a member in good standing with the Nebraska Bar. (__) I have demonstrated experience in, and knowledge of, the Nebraska Criminal Procedure statutes and the Nebraska Rules of Evidence. (__) I acknowledge that I must comply with Neb. Ct. R. of Prof. Cond. � 3-501.1, which states that a lawyer shall provide competent representation to a client. Competent representation requires the legal knowledge, skill, thoroughness, preparation, and judgment reasonably necessary for the representation. Therefore, if I feel I cannot properly represent the defendant on his/her charges, I shall immediately inform the judge of the court presiding over the case and request that I be allowed to withdraw from the case. (__) I acknowledge that I am being personally appointed and not the law firm, if any, of which I may be associated. (__) I acknowledge that if any of the above information changes, I shall immediately notify the County Court. (__) I acknowledge that if I no longer wish to receive court appointments, I will immediately notify the County Court. My name will then be removed from the list. Date: _____________ Signature: ____________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com