Affidavit Of Eligibility And Request For Court-Appointed Counsel For Criminal Non-Support And Probation Violation
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Affidavit Of Eligibility And Request For Court-Appointed Counsel For Criminal Non-Support And Probation Violation Form. This is a Oregon form and can be use in Marion Local County.
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S T AT E O F OR E GO N
Ma rion C oun ty
AFFIDAVIT OF ELIGIBILITY AND REQUEST FOR
COURT-APPOINTED COUNSEL FOR CRIMINAL
NON-SUPPORT AND PROBATION VIOLATION
Ca se N o.:
(No n-paym ent of fee s cases only)
STATE OF OREGON,
I am asking for appointment of an attorney in this case because I cannot pay for an attorney now without causing substantial
hardship to myself or my dependent family. The following information is complete and accurate to the best of my knowledge, and
I ask the court to use the information to decide whether I or my child can have an appointed attorney and payment of other defense
costs at public expense. I understand that I can be required to document or verify this information. I understand that failure to do
so could result in my request being denied, or if counsel has already been appointed, the withdrawal of counsel. I understand that
if I do not tell the truth, I can be required to repay the cost to the state for providing court-appointed counsel and/or I can be charged
with a crime, and if convicted, I can be incarcerated.
BE SURE TO READ THE “ADVICE OF RIGHTS” FORM
P L E A S E PR I N T C L E A R LY A N D C O M P L E TE E V E R Y LI N E B E L O W T H A T I S A P P L IC A B L E TO Y O U – IF S O M E T H IN G D O E S N O T A P P L Y , W R I T E " N A "
Full Nam e
F IR S T
Telephone No. (
C I TY
S T A TE
Date of Birth
9 Ma le
Social Sec urity No.
MONTH / DAY / YEAR
List the following information for everyone living in your household:
N am e
Have you ever requested a court-appointed attorney before this application?
If “yes,” which county?
Have you ever been denied a court-appointed attorney?
If “yes,” which county?
I understand that I may be required to pay a $20 application fee for the processing of this application. If I receive the services of
a court-appointed attorney, I understand that I may be required to pay a contribution amount and/or I may be required to reimburse
the state for reasonable court-appointed attorney fees and costs regardless of the outcome of the case. Any order for payment of
these fees or costs will be based upon my financial ability to pay such fees and costs. I understand I may request the court waive
all or part of the potential fees and costs.
I acknowledge receipt of the Advice of Rights form by initialing as follows:
I certify and affirm that I have read the information contained in this form, personally completed this application or requested its
completion, and that all statements contained herein are true and complete.
9 Applicant has completed this affidavit.
S IG N A T U R E O F A P P L IC A N T
9 Applicant has requested or allowed court / release office personnel to
complete affidavit utilizing information the applicant has provided.
SUBSCR IBED AND SW ORN TO before me this
CLERK OF COURT
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