FORM SUMMARY ______________________________________________________________________________ Name of Forms: Petition for Appointment of Counsel, Affidavit of Indigency and Order Form Number: GF-152 ____________________________________________________________________ Statutory Reference: United States Constitution, Amendment 6; Wisconsin Constitution Article 1, §7; Supreme Court Order 93-15, §§48.23; 51.20(3), 814.29, 977.08(3), Wisconsin Statutes Purpose of Form: This petition and affidavit is to be completed by an individual seeking appointment of counsel at county expense after having been deemed not indigent under state public defender guidelines. The court will use the Court Order section to grant or deny the relief. RMC anticipates that this form can be used to appoint counsel for persons in many different types of cases, including defendants in criminal matters, parents in CHIPS or TPR cases, subjects of involuntary mental commitment proceedings, or other proceedings. It uses the same standards and format established for the affidavits of indigency found in form CV-410. Who Completes It: The party seeking the indigency determination will complete the affidavit. The judge will complete the Court Order portion after reviewing the affidavit. Distribution of Form: Original to court. Copy to district attorney and attorney appointed. The party seeking the indigency determination will probably keep a copy. Accompanying Forms: Generally none, except some courts may require a copy of the appropriate pleadings (criminal complaint, petition for mental commitment, CHIPS petition, etc.) to be attached to the petition in order to assist in making a determination of the probable costs of representation. New Form/Modification: Modification, last update 04/08. Modifications: Added “/Rent” to “mortgage. Comments: Although a person may not meet state public defender guidelines for appointment of counsel or the state public defender may be prohibited from appointing counsel, there may still be constitutional or other considerations why counsel should be appointed at county expense. This form allows the person to petition the court for appointment of counsel, complete an affidavit of indigency and deliver it to court. The court would review the affidavit and make a determination of indigency and appoint counsel if appropriate. If counsel is appointed, the court must: • • designate the attorney to be appointed and the payment rate for the attorney (SPD rates or other), and, make a determination of whether the county should be reimbursed for the costs of that appointment and the schedule of payments that should be made. The court may deny the request if: Date: 01/08/2009 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com • • About this form: The person is not indigent (including if the affidavit is deemed to be untrue), or Other reasons. For example, in Joni B. v. State, 202 Wis.2d 1, 549 N.W.2d 411 (1996), the court set standards for determining the appropriateness of appointing counsel for parents in CHIPS cases. This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 01/08/2009 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com COUNTY STATE OF WISCONSIN, CIRCUIT COURT, For Official Use Petition for Appointment of Counsel, 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 and request that the court appoint counsel for me. 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. Section 1. If you do not receive aid, complete Section 2 on page 2. I currently receive: Medical assistance Relief funded under §59.53(21), Wis. Stats. Supplemental security income Relief funded under public assistance Food stamps Benefits for veterans under §45.351(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: has not changed since I became eligible for this program. has My financial situation 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 on page 2 of this form. Subscribed and sworn to before me on I understand that if my financial situation changes, I must notify the court immediately. Signature Date Address Notary Public/Court Official Telephone Number My commission expires: COURT FINDINGS AND ORDER 1. This petition is GRANTED because the court finds the person is currently indigent. Counsel 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. until the total sum is paid. The first per Repayment at the rate of $ . Payments shall be made to the Clerk of Court. payment shall be made on (date) 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. This petition is DENIED because the court finds: the person is not indigent. Other : THIS IS A FINAL JUDGMENT/ORDER FOR THE PURPOSES OF APPEAL. BY THE COURT: Circuit Court Judge Date Original: Clerk of Court/Register in Probate GF-152, 01/09 Petition for Appointment of Counsel, Affidavit of Indigency and Order US Constitution, Am. 6; Wis. Constitution Art. 1, §7; SCO 93-15; §§48.23, 51.20(3), 814.29, 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 Counsel, Affidavit of Indigency and Order Page 2 of 2 Case No. Section 2. Complete this section only if you do not qualify under Section 1, or if the instructions for that section require you to complete it. 1. I am am not married. 2. I am am not employed. Name of employer: gross weekly. 3. I earn $ My take-home pay is $ every 2 weeks. per pay period. twice monthly. monthly. from: 4. I receive gross monthly income totaling the amount of $ Unemployment compensation Social security Pension Other: Student loans/grants Disability 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: Household furnishings: $ Equity in real estate: $ $ others: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 8. The other members of my household have gross monthly income totaling the amount of $ Wages Pension Disability Other: Relief funded under public assistance Social security Unemployment compensation Student loans/grants 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: $ $ $ $ $ Yes Yes Yes Yes Yes No No No No No from: Food stamps Supplemental security income Support/maintenance Monthly Payment: 10. I have the following unusual expenses, other than ordinary living expenses: GF-152, 01/09 Petition for Appointment of Counsel, Affidavit of Indigency and Order US Constitution, Am. 6; Wis. Constitution Art. 1, §7; SCO 93-15; §§48.23, 51.20(3), 814.29, 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