UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE IN RE THE MATTER OF: _____________________________________ (Petitioner's name) Case No. _________________________ (If known) REQUEST FOR APPOINTMENT OF COUNSEL I, (name) respectfully request appointment of counsel to represent me as a G grand jury target G grand jury witness G criminal defendant G trial witness G other: ______________________________________________________________________ ______________________________________________________________________________ I am financially unable to hire counsel. A completed Financial Affidavit is attached. I declare under penalty of perjury that the foregoing is true and correct. Date: Signature of Petitioner NOTE FOR GRAND JURY OR WITNESS REPRESENTATION REQUESTS: In order for a request for counsel to be considered by the court, the petitioner must attach either a 1) grand jury target letter, or 2) witness subpoena. RULING BY JUDICIAL OFFICER G Request Approved. Appoint counsel. G Request Denied. Date: U.S. Magistrate Judge USDCNH-17 (Rev. 5-07) (Previous Editions Obsolete) American LegalNet, Inc. www.FormsWorkflow.com