STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use Amended Petition for Appointment of An Attorney, Affidavit of Indigency and Order -vs- Case No. UNDER OATH, I STATE THAT because of poverty, I am unable to pay for an attorney to represent me in this case. I petition the court for appointment of an attorney. I applied for representation through the state public defender, but was found ineligible for their services. Complete Section 1 if you receive aid from any of the programs listed. If you do not receive aid, complete Section 2 only. Section 1. I currently receive Supplemental security income. Relief funded under §59.53(21), Wis. Stats. Medical assistance. Food stamps/FoodShare. Relief funded under public assistance. Benefits for veterans under §45.40(1) or 38 USC 501-562. Legal representation from a civil legal services program or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. If you checked the “has” box, and such changes would make you ineligible for the program(s) if you applied today, you must complete Section 2. Section 2. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn (gross pay) $ weekly. My take-home pay (after taxes and deductions) is $ every 2 weeks. per pay period. twice monthly. monthly. 4. I receive gross monthly income totaling the amount of $ from Pension Social security Unemployment compensation Disability Student loans/grants Other: 5. I have the following cash assets: Savings accounts: $ Checking accounts: $ Cash: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Vehicle-Yr./Make: $ Other individual assets valued over $200 each: 7. My household consists of myself and Full name: Full name: Full name: Full name: Full name: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Relationship to me: GF-152, 08/11 Petition for Appointment of an Attorney, Affidavit of Indigency and Order Household furnishings: $ Equity in real estate: $ $ others: Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 Yes Yes Yes Yes Yes No No No No No US Constitution, Am. 6; Wis. Constitution Art. 1, §7; SCO 9315; §§48.23(4), 51.20(3), 814.29, and 977.08(3), Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Appointment of an Attorney, Affidavit of Indigency and Order Page 2 of 2 Case No. _______ 8. The other members of my household have gross monthly income totaling the amount of $ Wages Pension Disability Other: Social security Relief funded under public assistance Student loans/grants Unemployment compensation Relief funded under §59.53(21), Wisconsin Statutes 9. I have the following debts: a. Mortgage/Rent b. Auto loan c. Credit cards d. Other: Amount $ $ $ $ $ from Food stamps/FoodShare Supplemental security income Support/maintenance Monthly Payment 10. I have the following unusual expenses, other than ordinary living expenses: State of County of Subscribed and sworn to before me on I understand that if my financial situation changes, I must notify the court immediately.  Signature Date Notary Public/Court Official Print or Type Name Date of Birth Name Printed or Typed Address My commission/term expires: Telephone Number THE COURT FINDS AND ORDERS: This petition is 1. GRANTED because the court finds the person is currently indigent. An attorney shall be appointed at county expense as set forth below. The person shall be required to reimburse the county for such representation as follows: No reimbursement required. Repayment at the rate of $ per until the total sum is paid. The first payment shall be made on (Date) . Payments shall be made to the Clerk of Court. Other: The following attorney is appointed to represent the defendant: Name: Address: The attorney shall be compensated at current state public defender rates. $ Telephone Number: . 2. DENIED because the court finds the person is not indigent. Other : THIS IS A FINAL ORDER FOR PURPOSES OF APPEAL. Circuit Court Judge DISTRIBUTION: 1. Original: Clerk of Court/Register in Probate Date GF-152, 08/11 Petition for Appointment of an Attorney, Affidavit of Indigency and Order US Constitution, Am. 6; Wis. Constitution Art. 1, §7; SCO 9315; §§48.23(4), 51.20(3), 814.29, and 977.08(3), Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com