Financial Affidavit & Application For Court Appointed Counsel - New Hampshire
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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL
RSA:
Check Case Type:
Homicide
Felony (Non Homicide)
TPR
Misdemeanor Appeal
Abuse/Neglect
Misdemeanor
Delinquency/CHINS
Other
Supreme Court Appeal
This form must be filled out completely. If an item does not apply to you enter N/A. In this affidavit &
application you will swear that all the information is correct and state “I understand that I may be
required to repay the services provided me by court appointed counsel unless the court finds that I
am or will be financially unable to pay.”
Name:
Address:
Telephone:
Date of Birth:
Age:
Marital Status
Single
Married
Divorced
Separated
Widowed
List dependents you personally support:
(Include address if not same as yours. List relationship & age)
a.
c.
b.
d.
1. AVAILABLE MONEY
YOURS (A)
SPOUSES (B)
a. Cash on Hand .............................................................. $
$
b. Checking Accounts ...................................................... $
$
c. Savings Accounts ........................................................ $
$
d. Stock, Bonds, Trusts, CD’s, Other (CSVLI etc.) .......... $
$
TOTALS 1:
$
$
2. INCOME
a. Salary/Wages – Take home pay
$
$
(weekly
x 4.333=)
b. Alimony or Maintenance Received
$
$
(weekly
x 4.333=)
c. Child Support Received
$
$
(weekly
x 4.333=)
TOTALS 2:
$
$
3. EMPLOYMENT YOURS
SPOUSES
a. Employer:
b. Address:
Check:
Full Time
Part Time
Seasonal
Full Time
Part Time
Seasonal
4. HOUSING COSTS
a. Monthly Rent or Mortgage ........................................................................... $
b. Utilities (Electricity, heat, etc) ....................................................................... $
TOTALS 4: ................................. $
NHJB-2313-DFSSup (07/01/2013)
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