STATE OF OREGON Marion County Case No: ______________________ ___ Spouse Victim ____ In Custody AFFIDAVIT OF ELIGIBILITY* and REQUEST FOR COURT-APPOINTED COUNSEL (Not Public Information) Case Type: (ONLY IF NOT CRIMINAL OR PV) Charges: Case Name: 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. PLEASE PRINT CLEARLY AND COMPLETE EVERY LINE BELOW THAT IS APPLICABLE TO YOU IF SOMETHING DOES NOT 1. PERSONAL Full Name of Applicant ____________________________________________________________________________ FIRST NAME STREET ADDRESS ADDRESS MIDDLE NAME CITY CITY LAST NAME STATE STATE ZIP ZIP Residence Address _______________________________________________________________________________ Mailing Address (if different) ________________________________________________________________________ Telephone No. ( ) _ D.O.B. MONTH / DAY / YEAR ___ SSN: ___ ODL/ID: _____________________ Divorced Other: ____________ AREA CODE Sex: Female Male Marital Status: Married Single Separated List the following information for everyone living in your household: Name Relationship Age Monthly Net Income $______________________ $______________________ $______________________ 2. EMPLOYMENT AND INCOME Present employer How long Occupation __________________ Address Telephone No. ( ) ______________________ Hourly wage $ Average hours per week Net (after tax) monthly income $________________ If unemployed, how long since last employment ______________________________________________________ Previous employer Address How long Occupation __________________ Net (after tax) monthly income $________________ How long Occupation __________________ Address Telephone No. ( ) ______________________ Hourly wage $ Average hours per week Net (after tax) monthly income $_________________ If unemployed, how long since last employment _______________________________________________________ Other income for you and spouse, dependents or household members; for example, Social Security, unemployment, retirement, public Source of income - DESCRIBE Amount How long received How often received $___________ _________________ ______________________ $___________ _________________ ______________________ $___________ _________________ ______________________ Other household members who help pay for your living expenses: Name Amount Payment for what? - DESCRIBE $___________ __________________________________________ $___________ __________________________________________ OJIN CODE: AFIN OJIN EVT # IDEF-200:9/06 PAGE 1 - AFFIDAVIT OF ELIGIBILITY AND REQUEST FOR COURT-APPOINTED COUNSEL (*formerly Affidavit of Indigence) American LegalNet, Inc. www.FormsWorkFlow.com 3. PROPERTY AND ASSETS OWNED BY YOU, SPOUSE AND DEPENDENTS Cash $ Savings Account No. Checking Account No. Other Account No. Real Estate: Address, City If in custody, amount in jail or trust account $_________________ Balance $ Bank / Branch Office _________________________ Balance $ Bank / Branch Office _________________________ Balance $ Bank / Branch Office _________________________ Year of Purchase Purchase Price Value Amount owed Real estate payments made to $ $ Credit Cards: Card Name / Bank $ $ Account No. $___________ ____________________________ $___________ ____________________________ Current Balance $ $ Credit Limit $___________________ $___________________ Value Amount owing Vehicle payments made to $ $______________ ____________________________ $ $______________ ____________________________ Are any of these motor vehicles used for work (other than driving to and from work)? Yes No All other property or assets; for example, luxury items, antiques, boats, guns, jewelry, tools, etc.: Description Value Description Value $ $____________ $ $____________ Money owed to you or spouse by others; for example, tax refund, trust, settlement, judgment, etc.: Name of debtor Amount owed Date expected $_____________ ________________________ $_____________ ________________________ 4. MONTHLY EXPENSES List all expenses that are actually paid monthly by you individually or by you jointly with spouse: Rent / mortgage $ Utilities $ Food $ Credit card payment(s) $_____________ Car payment(s) $ Insurance $ Other: $__________________ Medical debts $ Child care $ Court-ordered fines/fees $_________________ Child support $ Name of children / ages:_________________________________________ 5. APPLICANT HISTORY I have $ security / bail posted on this or other pending cases. Have you ever requested a court-appointed attorney before this application? Yes No -appointed attorney was: Approved Denied In which county was your request? Date Charge(s) or type of case___________________ 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 courtappointed 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. ______________ DATE Applicant has completed this affidavit. SUBSCRIBED AND SWORN TO before me this __________________________________________________________ SIGNATURE OF APPLICANT Applicant has requested o