Offense(s):__________________________________________________ ___ Date of Offense:__________________ Date of Arrest:_________________ Primary Language:______________________ INS Hold yes no Incarcerated yes no Date application completed:_________________________ AFFIDAVIT IN SUPPORT OF COURT APPOINTED ATTORNEY By signing this application you are swearing, under oath, that an attorney does not now represent you, that your right to representation by an attorney has not been waived and that the information that you are providing is true and correct. To be considered for court appointed counsel, every question on this form must be answered. If the question does not apply to you, place an N/A in the blank. Failure to answer every question could result in your application not being considered. If you need assistance, notify the person in charge of taking this application. If you are not incarcerated, you MUST provide supporting documents such as payroll stubs, proof that you are receiving public assistance of any kind, and any other documents requested by the Court. Section 1. Personal Information Last name:_______________________________________ First name:_______________________________ Middle:______________________ Address:__________________________________________________________________ Married Divorced Single Other______________ Texas Driver's License or Identification Number:_________________________ Date of Birth:____________ Place of Birth:____________________ Home Phone: (____)_________________ Cell Phone: (____)_________________ Other Contact No. (____)______________________________ Employment Information. Place of Employment:________________________________________________ Length of Employment:_________ mo years Hourly pay rate: $________________ Number of Hours per week _________________ Net (after taxes) monthly salary: $___________________ List Deductions (except taxes) from payroll and the amount of each deduction: Child support $_________ Uniforms $_________________________ Savings/retirement $_____ Cash advance/loans $_______ Other $________________________________________________________ *If unemployed, give the length of time unemployed, reason for employment and explanation as to how your monthly expenses are paid or how you support yourself.___________________________________________ Do you have any diagnosed disability that prevents you from working? _______ List names of all employers for last two years and monthly salary for each. Employer's Name and Superviser Dates of Employment Monthly Net Income (Take home pay) Spouse's Information: Spouse's Name ____________________________ Place of Employment _________________________ Net (after taxes) monthly salary$________ Hourly pay rate: $_____ Number of hours per week: ______ List Deductions (except taxes) from payroll and the amount of each deduction: Child support $_____ Uniforms $______ Savings/retirement $_____ Cash advance/loans $_____ Other $_________ Government Assistance: Are you receiving government benefits for yourself, spouse or biological/adopted children? yes no AFDC $_______ per month SSI $_______ per month Disability $_______ per month Medicaid $_______ per month Food Stamps $_______ per month Child Support $_______ per month Other: (Specify type of benefit and amount per month):___________________________________________________________ Financial Information: Do you have any property that you could sell or use as collateral? yes no If yes, then list item with approximate value_________________ yes no Do you have any friends or relatives from which you can borrow funds for an attorney? Real Estate 1. Do you own any real estate? yes no Homestead Rental Business Other:____________________________________ Address of Property:____________________________________________________________________________________________________ Date purchased ___________ Purchase price: $___________Tax Appraisal value $_____________ Amount owed on property $_____________ 2. Do you own any real estate? yes no Homestead Rental Business Other:__________________________________ Address of Property:____________________________________________________________________________________________________ Date purchased ___________ Purchase price: $___________Tax Appraisal value $_____________ Amount owed on property $_____________ (Please use back of sheet to list additional properties owned or being purchased by you) Motor Vehicles: List all vehicles, including boats, motorcycles, and recreational vehicles titled in your name Year, Model and Make of Vehicle:______________________________________________________ Estimated value:____________ Year, Model and Make of Vehicle:______________________________________________________ Estimated value:____________ Year, Model and Make of Vehicle:______________________________________________________ Estimated value:____________ Application American LegalNet, Inc. www.FormsWorkFlow.com 1 Personal Property: Clearly indicate all assets currently in your name or subject to your control and the value of each Securities/Bonds/CDs $______ Livestock $_________ Whole Life Insurance $______ Cash money $_________ Retirement Plans $_________ Bank Accounts $______ Savings Accounts $_________ Available credit $________ Section 2: Debts and Liabilities. List all dependents (spouse, biological and legally adopted children) living with you. Name Relationship Age Name Relationship Age Monthly Expenses: Necessary monthly expenses are as follows Rent/House payment $______ Food $______ Fuel/Maintenance $______ Cell Phone $______ School tuition $______ Church $______ Medical Insurance $______ Auto insurance $______ Other transporation $______ Haircuts/Nails $______ Furniture payments $______ Entertainment $______ Other $______ Other $______ Section 3: Miscellaneous Information Are there any co-defendants in your case? yes (if amount is $0.00, place a 0 or N/A in the blank Utilities $______ Telephone $______ Child Care $______ School Lunches $______ Credit Cards $______ Doctor/Dentist $______ Life Insurance $______ Auto payment $______ Bank Loans $______ Cable/Satellite $______ Clothing $______ Child Support $______ TOTAL MONTHLY EXPENSES: $_____________ no Please name co-defendants to avoid attorney conflicts. ____________________ References: List the name, address and telephone number of 3 individuals who are able to contact you regarding your case. Name Phone number with area code Address Relationship Section 4: