COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : ELEVENTH DISTRICT COURT STATE OF NEW MEXICO COUNTY OF SAN JUAN Index No. : Plaintiff(s) STATE OF NEW MEXICO -against- Calendar No. : JUDICIAL SUBPOENA : VS. NO. : ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICES : NAME: DOB: Defendant(s) : AKA: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .M . F . SS#:. . . . SEX: . . . . . . ... ADDRESS: PHONE: CHARGES: DC# MC# +), +), THE PEOPLE OF THE STATE OF NEW YORK +), +), AGE +), +), LIVES ALONE:.)- WITH: SPOUSE.)- CHILDREN.)- PARENT.)- FRIEND(S).)- OTHER.)- TO +), +), +), +), +), +), MARITAL STATUS:.)- SINGLE .)- MARRIED .)- DIVORCED .)- SEPARATED .)- WIDOWED.)NUMBER OF FAMILY IN HOUSEHOLD: PRESUMPTIVE ELIGIBILITY: +), GREETINGS: .)- I currently do not receive public assistance. +), WE COMMAND YOU, following type of public laid aside, you and .)- I currently receive the that all business and excuses beingassistance in each of you attend before , the Honorable at the Court COUNTY located at County of +), in AFDC , on the day of , 20 , at o'clock in the $ noon, and at any recessed .)- room $ Food Stamps $ Medicaid $ SSI +), adjourned date, to testify and give evidence as a witness in this action on the part of the or .)- Other (specify type and amount): NET INCOME: SELF FAMILY IN HOUSEHOLD Employer's Name Employer's Phone to comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure Pay party on whose behalfevery 2nd week,issued formonthly, monthly) $50 and all damages sustained as a the period (weekly, this subpoena was twice a maximum penalty of result of your failure to comply. Net take home pay (salary/wages minus deductions required by law) $ $ Witness, Honorable , one$ the Justices of the of Other income sources (please specify) $ SCREENING Court in County, day of , 20 $ $ USE ONLY TOTAL ANNUAL INCOME $ + $ =/ /A ASSETS: Cash on hand $ $ (Attorney must sign above and type name below) Bank Accounts $ $ Real estate Equity$ $ Equity$ $ Motor Vehicles Equity$ Attorney(s) for $ Equity$ $ Other Personal Property (described): Equity$ $ SCREENING Equity$ $ USE ONLY P.O. TOTAL ASSETS $ Office and + $Address =/ /B EXCEPTIONAL EXPENSES (Total exceptional expenses of family) Medical Expenses (list only unusual and continuing expenses)$ Court-order support payments/alimony $ Telephone No.: Child-care payments (e.g.,day care) $ Facsimile No.: $ Other (describe): ) SCREENING E-Mail Address:$ ) USE ONLY TOTAL EXPENSES Mobile Tel. No.: $ =/ /C *P/G/C means parents(s)/guardian/custodian. American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : STATE OF NEW MEXICO COUNTY OF SAN JUAN : Index No. Calendar No. This statement is made under oath; any false statement of a material fact to : JUDICIAL SUBPOENA Plaintiff(s) any question contained herein shall constitute perjury. I hereby state that the above information is correct -against- best of my knowledge. : I hereby authorize the screening to the agency, District Defender, and/or courts to obtain information from financial institutions, employers and/or the I.R.S. regarding: my financial condition. : Defendant(s) : ...................................................... DATE SIGNATURE OF DEFENDANT SWORN/AFFIRMED AND SIGNED BEFORE ME THIS DAY. THE PEOPLE OF THE STATE OF NEW YORK TO DATE SIGNATURE AND TITLE GREETINGS: MY COMMISSION EXPIRES WE COMMAND PLUS COLUMN "B"(ASSETS) COLUMN "A"(NET INCOME) YOU, that all business and excuses being laid aside, you and each ofONLYattend before SCREENING USE you , the Honorable "C"(EXCEPTIONAL EXPENSES) at the Court AVAILABLE FUNDS MINUS COLUMN located at County of EQUALS AVAILABLE FUNDS....................................=/ / in room , on the day of , 20 , at o'clock in the noon, and at any recessed INDIGENCY TABLE: testify and give evidence as a witness in this action on the part of the or adjourned date, to HOUSEHOLD SIZE(SELF & FAMILY ONLY) 1 2 3 4 AVAILABLE FUNDS(ANNUALLY) $8,512 $11,487 $14,462 $17,437 ADD $2.975.00failure EACH ADDITIONAL subpoena is punishable as a contempt of court and will make you liable to Your FOR to comply with this FAMILY MEMBER. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result THE DEFENDANT comply. of your failure to IS INDIGENT THE DEFENDANT IS NOT INDIGENT. Witness, Honorable Court in County, , one of the Justices of the day of SIGNATURE OF SCREENING AGENT , 20 TITLE (Attorney must sign above and type name below) Based on the above answers and information, I find that the DEFENDANT (is)(is not) and indigent person and that an attorney on contract with the Public Defender Department (shall)(shall not) represent the defendant in theAttorney(s) for above entitled case. Office and P.O. Address JUDGE Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com