(TYPE OR PRINT IN BLACK INK) In The General Court Of Justice District Superior Court Division File No. Additional File Nos. STATE OF NORTH CAROLINA Name Of Applicant County AFFIDAVIT OF INDIGENCY Offense(s) Street Number And Street Name, Including Apartment Or Unit Number If Applicable G.S. 7A-450 et seq. City, State And Zip Code Full Permanent Mailing Address Of Applicant (If Different Than Above) Name Of Lawyer Telephone Number Of Applicant Date Of Birth Applicant: Do you have other pending criminal charge(s) Yes in which a lawyer has been appointed? No Full Social Security No. Of Applicant Defendant Parent/Guardian/Trustee MONTHLY INCOME (money you make) Employment - Applicant Name And Address Of Applicant's Employer Has No Social Security No. MONTHLY EXPENSES (money you pay out) $ Number Of Dependents Shelter Utilities Buying Renting (If not employed, state reason; if self-employed, state trade) $ $ $ $ Food (including Food Stamps) (power, water, heating, phone, cable, etc.) Other Income (Welfare, Food Stamps, S/S, Pensions, etc.) $ $ Health Care Installment Payments Vehicle Other Employment - Spouse Name And Address Of Spouse's Employer $ $ $ $ $ (amounts you owe) (gas, insurance, etc.) Car Expenses Support Payments Other: (specify) Total Monthly Income Cash On Hand And In Bank Accounts (List Name Of Bank & Account No.) $ Total Monthly Expenses (things you own) DESCRIPTION OF ASSETS AND LIABILITIES $ Money Owed To Or Held For Applicant Motor Vehicles (List Make, Model, Year) $ Real Estate Personal Property Other Debts Last Income Tax Filed 20 Other Total Assets And Liabilities Bond Type Amount ASSETS LIABILITIES $ (Fair Market Value) (Balance Due) $ (Fair Market Value) (Fair Market Value) $ $ $ $ $ (Balance Due) (Balance Due) Refund Owe $ $ $ By Whom Posted $ $ $ $ NOTE: Read the notice on the reverse side before completing this form. AOC-CR-226, Rev. 10/13 © 2013 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO PERSONS REQUESTING A COURT-APPOINTED LAWYER 1. When answering the questions on the Affidavit Of Indigency (reverse side of this form), please do not discuss your case with the interviewer. The interviewer can be called as a witness to testify about any statements made in his/her presence. Please wait and speak with your lawyer. Do not ask the interviewer for any advice or opinion concerning your case. 2. A court-appointed lawyer is not free. If you are convicted or plead guilty or no contest, you may be required to repay the cost of your lawyer as a part of your sentence. The Court may also enter a civil judgment against you, which will accrue interest at the legal rate set out in G.S. 24-1 from the date of the entry of judgment. Your North Carolina Tax Refund may be taken to pay for the cost of your court-appointed lawyer. In addition, if you are convicted or plead guilty or no contest, the Court must charge you an attorney appointment fee and may enter this fee as a civil judgment against you pursuant to G.S. 7A-455.1. 3. The information you provide may be verified, and your signature below will serve as a release permitting the interviewer to contact your creditors, employers, family members, and others concerning your eligibility for a court-appointed lawyer. A false or dishonest answer concerning your financial status could lead to prosecution for perjury. See G.S. 7A-456(a) ("A false material statement made by a person under oath or affirmation in regard to the question of his indigency constitutes a Class I felony."). Under penalty of perjury, I declare that the information provided on this form is true and correct to the best of my knowledge, and that I am financially unable to employ a lawyer to represent me. I now request the Court to assign a lawyer to represent me in this case. I authorize the Court to contact my creditors, employers, or family members, any governmental agencies or any other entities listed below concerning my eligibility for a court-appointed lawyer. I further authorize my creditors, employers, or family members, any governmental agencies or any other entities listed below to release financial information concerning my eligibility for a court-appointed lawyer upon request of the Court. Governmental Agencies Or Other Entities Authorized To Be Contacted And/Or To Release Information SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Signature Date Signature Of Applicant Name Of Applicant (Type Or Print) Deputy CSC Notary Assistant CSC Clerk Of Superior Court Magistrate Date My Commission Expires County Where Notarized Defendant Parent/Guardian/Trustee SEAL NOTE: If you are less than 18 years old, or if you are at least 18 years old but remain dependent on and live with a parent or guardian, state name and address of parent, guardian or trustee below. Name Of Parent/Guardian Or Trustee Address City, State, Zip AOC-CR-226, Side Two, Rev. 10/13 © 2013 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com