STATE OF SOUTH CAROLINA ) ) COUNTY OF ____________________ ) ) ) ) Plaintiff, ) ) vs. ) ) ) Defendant. ) IN THE FAMILY COURT _____JUDICIAL CIRCUIT AFFIDAVIT OF INDIGENCY AND APPLICATION FOR COUNSEL (Defense of Indigency Act, Form No.2) Docket No. ___________________________ NAME OF APPLICANT ADDRESS TELEPHONE NUMBER(S) DATE OF BIRTH SOCIAL SECURITY NO. NAMES OF CO-DEFENDANTS 1. Are you presently employed? Yes No a. If “yes”, state the amount of your salary or wages per month, and give the name and address of your employer. SALARY OR WAGES PER MONTH NAME AND ADDRESS OF EMPLOYER If “no”, state the name and address of last employment, date of termination of employment, and amount of your salary or wages per month. SALARY OR WAGES PER MONTH 2. NAME AND ADDRESS OF EMPLOYER TERMINATION DATE Include employment information for the spouse, if applicable. SALARY OR WAGES PER MONTH NAME AND ADDRESS OF EMPLOYER If the spouse is not currently employed, state the name and address of last employment, date of termination of employment, and amount of salary or wages per month. SALARY OR WAGES PER MONTH NAME AND ADDRESS OF EMPLOYER TERMINATION DATE SCACRVIFORM02DR (12/2009) American LegalNet, Inc. www.FormsWorkFlow.com 3. List by name, age and relationship to you, any persons who are dependent upon you for support. Indicate beside each how much you contribute toward their support. NAME 4. AGE RELATIONSHIP AMOUNT OF SUPPORT Have you received within the past twelve months any money from any of the following sources? a. Business, profession or form of self-employment? Yes No b. Rent payments, interest or dividends? Yes No c. Pensions, annuities or life insurance payments? Yes No d. Gifts or inheritances? Yes No e. Any other sources? Yes No If the answer to any of the above is “yes”, describe each source of money and state the amount received from each during the past twelve months. SOURCE OF MONEY 5. AMOUNT Do you own cash, or do you have any money in a checking or savings account? Yes No If the answer is “yes”, state the total amount of the cash owned. 6. __________________________ Do you own any real estate, stocks, bonds, notes, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is “yes”, describe the property and state the appropriate value of the items owned. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7. What kind of motor vehicle do you own? ___________________________________________ Is it paid for? Yes No If not, what are the payments? ______________________________________________________ 8. How much do you owe (on liens, mortgages, other encumbrances or debts)? _______________ ________________________________________________________________________________ SCACRVIFORM02DR (12/2009) American LegalNet, Inc. www.FormsWorkFlow.com I do solemnly swear that the account by me delivered into this court with my application for counsel does contain a true and full account of all my real and personal estate, debts, credits and effects whatsoever without exception, which I or any person in trust for me have or at the time of my possession had, or am, or was, in any respect, entitled to, in possession, remainder or reversion and that I have not at any time since charges were made against me or before, directly or indirectly sold, leased, assigned or otherwise disposed of or made over, in trust for myself or otherwise, other than is mentioned herein. I understand the appointment of counsel creates a claim against the assets and estate of the person who is provided counsel or the parents or legal guardians of a juvenile in an amount equal to the cost of representation less the amount paid to appointed counsel, the public defender office and/or the Commission on Indigent Defense. I understand that such claim shall be filed in the office of the Clerk of Court in the county where I, my child, or ward are assigned counsel, but that the filing of a claim shall not constitute a lien against my real or personal property unless, in the discretion of the court, part of all of such claim is reduced to judgment by appropriate order of the court after serving me with at least thirty (30) days notice that judgment will be entered. I understand that, pursuant to §17-3-30(b), I am required to pay a non-refundable $40.00 application fee to the Clerk of Court for public defender services or other appointed counsel. I am financially unable to employ counsel and request that counsel be assigned to represent me. I understand that I am entitled to at least thirty days’ notice before a claim against me may be reduced to judgment, and I do hereby waive the right to such notice. This _____day of _______________________, ______ ______________________________ Applicant Subscribed and sworn to before me this day of , (L.S.) Notary Public for South Carolina My Commission Expires: The applicant’s request for court-appointed counsel is hereby granted / denied. Dated: _____________________ Judge/Clerk or Deputy Clerk ______________, South Carolina SCACRVIFORM02DR (12/2009) American LegalNet, Inc. www.FormsWorkFlow.com