IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF TILLAMOOK In the Matter of the Application of _____________________________________ Petitioner, vs. _____________________________________ (Name of Custodian of Superintendent-Title) Defendant. ) ) ) ) ) ) ) ) ) Case No. __________________ (To Be Supplied by Court Clerk) ) PETITIONER'S MOTION TO PROCEED AS AN INDIGENT PERSON AND FOR APPOINTMENT OF COUNSEL Pursuant to ORS 138.590, Petitioner respectfully moves this Court to waive the prepayment of the court costs, fees and expenses to this action. Petitioner further moves for appointment of suitable counsel to assist and represent Petitioner in this proceeding. This Motion is based upon the attached Affidavit of Indigency indication that Petitioner is without the funds and/or assets necessary to pay the expenses of this proceeding or to retain counsel. Dated: ______________________________, 20_______. Respectfully submitted, ______________________________________________ (Petitioner's Signature) Page 1- Petitioner's Motion to Proceed as an Indigent Person and for Appointment of Counsel American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF INDIGENCY STATE OF OREGON County of Tillamook ) ) ss. ) Case No. ____________________ I, ________________________________ being duly sworn, on oath, depose and say: That I make this Affidavit in connection with the attached Petition For Post Conviction relief That I am financially unable to bear any of the costs, expenses or fees incurred herein; and that the following is the best estimate of my assets, liabilities and income during the previous year. Net income during the previous 12 months..........................................$___________________ Money on hand, in savings, trust account, with Superintendent, etc...........................................................$___________________ Real property (house, land, etc.)...........................................................$___________________ Personal property(cars, tools, TV, etc.)................................................$____________________ Money owed to me by others................................................................$____________________ Money I owe to others..........................................................................$____________________ Other assets (examples: stocks, bonds)................................................$____________________ Other liabilities (examples: restitution, child support, fines)...............$____________________ _________________________________ Petitioner's Signature SUBSCRIBED AND SWORN to before me this ________ day of _________________, 20___. __________________________________ NOTARY PUBLIC FOR OREGON My Commission Expires: _____________ Page 2- Affidavit of Indigency American LegalNet, Inc. www.FormsWorkFlow.com