10-707. Eligibility determination for indigent defense services. [For use with Rule 10-223 NMRA]STATE OF NEW MEXICOCOUNTY OF JUDICIAL DISTRICTIN THE CHILDREN222S COURTIn the Matter of , a Child.No. ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICESChild222s Name: DOB: Age: AKA: Sex: Male Female SSN: Child222s Address: Phone: P/G/C222s Name1: Phone: P/G/C222s Address1: Phone: Charges: Child Lives with: Alone: Lives with: Spouse Children Parent Friend Other Parent222s Marital status: Single Married Divorced Separated WidowedNumber of dependents in household: [ ] Child is in detention. [ ] Child is not in detention.[ ] Child is in legal custody of CYFD or other Public Agency.PRESUMPTIVE ELIGIBILITY:Parents/guardian/custodian DOES NOT receive public assistance.Parents/guardian/custodian receives the following type of public assistance in County:DEPARTMENT OF HEALTH CASE MANAGEMENT SERVICES (DHMS) $TANF/GA $ Food Stamps $ Medicaid $Public Housing $ SSI/SSDI $ VA Disability Unable to complete application because of possible Mental Health/Developmental Issue ofParent/Guardian/Custodian.NET INCOME:CHILDPARENT, GUARDIAN,CUSTODIANEmployer222s Name Employer222s Phone Pay Period(weekly, every second week,twice monthly, monthly)Net take home pay (salarywages minus deductions required by law)$$Other income sources (please specify)$$ American LegalNet, Inc. www.FormsWorkFlow.com SCREENING USE ONLYTOTAL ANNUAL INCOME$ + =// AASSETS: CASH ON HAND$$ BANK ACCOUNTS$$ REAL ESTATE (equity)$$$$ MOTOR VEHICLES (equity)$$$$ OTHER PERSONAL PROPERTY (equity): (describe and set forth equity)$$$$SCREENING USE ONLYTOTAL ASSETS$ + =// BEXCEPTIONAL EXPENSES (total exceptional expenses of dependents): MEDICAL EXPENSES (not covered by insurance)$ MEDICAL INSURANCE PAYMENTS (receipts required)$ COURT-ORDER SUPPORT PAYMENTS/ALIMONY$ CHILD-CARE PAYMENTS (e.g. day care)$ OTHER (describe) $ $SCREENING USE ONLYTOTAL EXCEPTIONAL EXPENSES$ =// CI UNDERSTAND THAT I WILL BE CHARGED IF THE ABOVE-NAMED CHILD IS REPRESENTED BY THEPUBLIC DEFENDER DEPARTMENT AND I AM NOT INDIGENT AS DETERMINED BY THE PUBLICDEFENDER STANDARD.STATE OF NEW MEXICO)) ssCOUNTY OF )This statement is made under oath. I hereby state that the above information is correct to the best of myknowledge. I hereby authorize the screening agent, district defender, and the court to obtain information regardingmy financial condition from financial institutions, employers, relatives, the internal revenue service, and other stateagencies.DateSignature of parent(s)/guardian/custodianI UNDERSTAND THAT I WILL BE CHARGED IF THE ABOVE-NAMED CHILD IS REPRESENTED BY THEPUBLIC DEFENDER DEPARTMENT AND I AM NOT INDIGENT AS DETERMINED BY THE PUBLICDEFENDER STANDARD. STATE OF NEW MEXICO)) ssCOUNTY OF )Signed and sworn to (or affirmed) before me on (date) by (name of American LegalNet, Inc. www.FormsWorkFlow.com parent, guardian, or custodian).Notary(Seal, if any)My commission expires: I UNDERSTAND THAT IF IT IS DETERMINED THAT I AM NOT INDIGENT, I MAY APPEAL TO THECOURT WITHIN TEN (10) DAYS AFTER THE DATE I AM ADVISED OF THIS DECISION.I wish to appeal.I do not wish to appeal.DateSignature of parent/guardian/custodianCOLUMN "A" (net income) plus COLUMN "B" (assets)SCREENING USE ONLYminus COLUMN "C" (exceptional expenses)AVAILABLE FUNDSequals AVAILABLE FUNDS / / ........................................................ The parent/guardian/custodian is indigent.The parent/guardian/custodian is not indigent.The parent/guardian/custodian applicant [has] [has not] paid the $10.00 application fee.Receipt number: Based on the above answers and information, I find that the applicant [is] [is not] indigent.Signature of screening agentTitleI find that the parents/guardian/custodian is unable to pay the $10.00 indigency application fee due to and I therefore waive the payment of the $10.00application fee.Signature of Screening Agent1P/G/C means parent(s)/guardian/custodian2Dependent means any person who qualifies as a dependent of the applicant under Section 152 of theInternal Revenue Code. The Public Defender Department is committed to a policy against discriminationbased on race, color, religion, national origin, age, sex, ancestry, veteran status, or mental or physicaldisability.GUIDELINES FOR DETERMINING ELIGIBILITYPursuant to Section 31-15-7 and 32A-2-30 NMSA 1978, the following guidelines areestablished for determination of indigency and eligibility for public defender services in juvenilecases. American LegalNet, Inc. www.FormsWorkFlow.com I.APPLICATION FEEA person shall pay a non-refundable application fee for each case in the amount set inSection 35-15-12 NMSA 1978 at the time the person applies with the public defender forrepresentation. The interviewer will determine if the financial circumstances of the applicant aresuch that the fee would pose an exceptional hardship, and will recommend to the District officeAdministrator or Eligibility Supervisor if the fee should be waived. The interviewer willdocument on the application the reason for the fee waiver.II.PRESUMPTION OF INDIGENCYA parent, parent(s), guardian, or custodian is presumed indigent if the parent(s), guardian,or custodian is a current recipient of state or federally administered public assistance programsfor the indigent: temporary assistance for needy families (TANF), general assistance (GA),supplemental security income (SSI), social security disability income (SSDI), Veteran222s disabilitybenefits (VA) if the benefit is the sole source of income, food stamps, Medicaid, public assistedhousing, or Department of Health, Case Management Services (DHMS). Proof of assistancemust be attached to the application and no further inquiry is necessary. The document submittedas proof must clearly identify the child, parent, guardian, or custodian as currently receiving thequalifying benefit. Benefit cards without other supporting documents will not be accepted asproof of benefit. If the applicant is not receiving Medicaid benefits, but has dependents in thehousehold for whom Medicaid eligibility has been determined, the applicant will be presumedindigent. Home equity, etc. is not to be taken into account if the parent(s), guardian, or custodianis a current recipient of one of the six programs described above. If the child is in the physicalcustody of the Children Youth and Family Department (CYFD) the parent(s), guardian, orcustodian is presumed indigent and no further inquiry is necessary.If the parent, guardian, or custodian is the alleged victim in the case for which applicationis being made, they will be approved for Public Defender representation and no further inquiry isnecessary.If the interviewer is unable to complete the indigency application or believes theinformation to be unreliable because of communication or other problems associated with amental or developmental disability of the parent/guardian/custodian, indigency will be presumed. If because of the mental disability of the parent/guardian/custodian, the inter-viewer is unable tocomplete the indigency application or believes the information is unreliable, the MentalHealth/Communication section of the application should be checked. The designated attorneyfor juvenile cases is to be immediately notified, and if that person is not available the dutyattorney is to be immediately notified.III.FINANCIAL RESOURCESIf the parent(s), guardian or custodian is not presumptively indigent, the screening agentshall examine the financial resources of the applicant with consideration given to: American LegalNet, Inc. www.FormsWorkFlow.com Net Income, Paragraph A;Assets, Paragraph B; andExceptional Expenses, Paragraph C.A.Net Income. The screening agent shall include total salary and wages for theapplicant and the applicant222s spouse minus deductions required by law (FICA, state and federalwithholding). Child support deductions and medical insurance deductions will also beconsidered if already deducted from salary, but will not be recounted in the Exceptional Expensessection if counted here. Savings deductions and non-mandatory retirement deductions will beadded to the net income. In order to calculate the salary of an individual,