Financial Affidavit & Application For Court Appointed Counsel - New Hampshire Page 3
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Case Number:
FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL
AUTHORIZATION FOR THE RELEASE OF INFORMATION
To whom it may concern:
I hereby authorize the State of New Hampshire, Office of Cost Containment, to obtain any and all
information with regard to my employment and financial condition from government agency, bank,
creditor or employer.
Date
Applicant Signature
State of
, County of
This instrument was acknowledged before me on
by
My Commission Expires
Affix Seal, if any
Signature of Notarial Officer / Title
FOR COURT USE
Application Approved: If approved this form and NE/NFL required – send to OCC.
Application Denied: If denied send this form to OCC. NE/NFL not required.
Date
Signature of Judge
Printed Name of Judge
(Signature required only if application denied)
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NHJB-2313-DFSSup (07/01/2013)
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