STATE OF NEW MEXICO COUNTY OF FIRST JUDICIAL DISTRICT COURT Petitioner, v. No. Respondent. MOTION FOR APPOINTMENT OF ATTORNEY COMES NOW , and moves this Court for an order allowing the appointment of an attorney. As grounds for this motion, movant states that because of indigency, I cannot afford to pay for an attorney to represent me. I have attached the affidavits required by the Administrative Order No. 2004-4. Signature of Applicant American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW MEXICO COUNTY OF FIRST JUDICIAL DISTRICT COURT Petitioner, v. No. Respondent. AFFIDAVIT OF INDIGENCY STATE OF NEW MEXICO ) ) ss. COUNTY OF ) I, , make under oath the following statements regarding my financial, marital and employment status, and since I am unable to pay for an attorney to represent me in the above-captioned case, make application to proceed in accordance with Administrative Order No. 2004-4. BACKGROUND AND RESIDENCE 1. Full name: 2. Age: 3. Present address: 4. How many years at this address? 5. Telephone No. 6. Marital Status: Married [ ] Single [ ] Divorced [ ] Separated [ ] American LegalNet, Inc. www.FormsWorkFlow.com Children Adult 7. Number of dependents (including yourself): 8. Ages of minor children living with you: 9. List name and relationship of adult dependents whom you support: Name: Relationship: EMPLOYMENT AND INCOME: 1 Employed [ ] Not Employed [ ] Self-employed [ ] 2. Name and address of employer: 3. Position: 4. Gross salary per month: $ 5. If self-employed, nature of business: American LegalNet, Inc. www.FormsWorkFlow.com OTHER INCOME: In addition to wages and salary, I receive the following income: A. Social Security / Disability $ B. Welfare $ C. Unemployment $ D. Food Stamps $ E. AFDC $ F. VA $ G. Child Support $ H. Alimony $ I. Investments $ Total: $ ASSETS 1. Do you own any real estate? Yes [ ] No [ ] A. Description: B. Location: C. Estimated present value $ D. Estimated outstanding mortgages or contracts on property:$ E. Payments per month:$ American LegalNet, Inc. www.FormsWorkFlow.com 2. Do you own any automobiles? Yes [ ] No [ ] A. Make/Model Year B. Present Value $ Total Amount Owed $ $ $ C. Monthly payments $ $ 3. Do you have any stocks or bonds? Yes [ ] No [ ] A. Description B. Present Value $ 4. Do you have cash in the bank? Yes [ ] No [ ] A. If so, indicate amount $ 5. Do you have any other assets not listed above excluding household furnishings and clothing? Yes [ ] No [ ] A. If so, describe and give value Value: $ DEBTS AND OTHER OBLIGATIONS: 1. The following are my current obligations: A. House payment / rent per month $ B. Utilities per month $ C. Telephone per month $ D. Groceries $ E. Gasoline $ American LegalNet, Inc. www.FormsWorkFlow.com F. Insurance $ G. Medical Bills $ H. Child Care $ I. Other $ J. Other $ Total: $ SIGNATURE OF APPLICANT SUBSCRIBED AND SWORN TO before me by this day of , . My Commission Expires: NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW MEXICO COUNTY OF FIRST JUDICIAL DISTRICT COURT Petitioner, v. No. Respondent. ORDER FOR APPOINTMENT OF ATTORNEY THIS MATTER having come before the Court on =s motion for appointment of an attorney, and showing of indigency by affidavit(s), and the Court being otherwise advised in the premises, the Court orders that the movant: 1. have the following attorney appointed: . 2. be denied the appointment of an attorney. DISTRICT COURT JUDGE American LegalNet, Inc. www.FormsWorkFlow.com