GF-152A, 11/18 Petition for Appointment of an Attorney, Affidavit of Indigency US Constitution, Am. 6; Wis. Constitution Art. 1, 2477; SCO 93-15; 24724748.23(4), 51.20(3), 814.29, and 977.08(3), Wisconsin Statutes, Supreme Court Order 17-06 This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY - vs - Amended Petition for Appointment of a n Attorney, Affidavit of Indigency 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. I was found eligible for a state public defender in this case on [Date] . The state public defender has not appointed an attorney to represent me within a reasonable time. Section 1. I currently receive Supplemental security income. Relief funded under 24759.53(21), Wis. Stats. Medical assistance. Food stamps/FoodShare. Relief funded under public assistance. Benefits for veterans under 24745.40 (1m) 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. Section 2. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn (gross pay) $ weekly. every 2 weeks. twice monthly. monthly. My take-home pay (after taxes and deductions) is $ per pay period. 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: $ Cash: $ Checking accounts: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Household furnishings: $ Vehicle-Yr./Make: $ Equity in real estate: $ Other individual assets valued over $200 each: $ 7. My household consists of myself and others: Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No American LegalNet, Inc. www.FormsWorkFlow.com GF-152A, 11/18 Petition for Appointment of an Attorney, Affidavit of Indigency US Constitution, Am. 6; Wis. Constitution Art. 1, 2477; SCO 93-15; 24724748.23(4), 51.20(3), 814.29, and 977.08(3), Wisconsin Statutes, Supreme Court Order 17-06 This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 8. The other members of my household have gross monthly income totaling the amount of $ from Wages Social security Relief funded under public assistance Food stamps/FoodShare Pension Student loans/grants Unemployment compensation Supplemental security income Disability Relief funded under 24759.53(21), Wisconsin Statutes Support/maintenance Other: 9. I have the following debts: Amount Monthly Payment a. Mortgage/Rent $ b. Auto loan $ c. Credit cards $ d. Other: $ $ 10. I have the following unusual expenses, other than ordinary living expenses: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: I understand that if my financial situation changes, I must notify the court immediately. Signature Date Print or Type Name Date of Birth Address (City, State, Zip) Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com