Financial Affidavit & Application For Court Appointed Counsel - New Hampshire Page 4
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4Case Name:
Case Number:
FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL
Financial Affidavit Worksheet
Enter totals listed on front of form.
STEP ONE.
Market Value of Property
7A.
$
Mortgage Owed
7B. (-) $
NET VALUE OF REAL ESTATE ................ > $
0.00
If value of real estate is equal to or greater than the amount listed on Financial Eligibility Table
(OCC Fm2) then the defendant is “INELIGIBLE” for indigent defense funds. Proceed to next
step regardless of results.
STEP TWO.
Available Money
1A.
$
1B. (+) $
Monthly Income
2A. (+) $
2B. (+) $
TOTAL PART ONE ............................................. > Line A $
0.00
Housing Costs
4.
$
Monthly Loan Payments
5. (+) $
Other Payments
6. (+) $
Minimum Living Exp (Individual)
(+) $
250.00
# Listed Dependents x $100.00
(+) $
0.00
TOTAL PART TWO ............................................ > Line B $
250.00
TOTAL FUNDS AVAILABLE FOR REPRESENTATION
Line A minus Line B ...... > Line C $
-250.00
If available funds for representation is equal to or greater than the amount listed on Financial
Eligibility Table (OCC Fm 2) then the defendant is “INELIGIBLE” for indigent defense funds. See
instruction manual.
If the defendant is “ELIGIBLE” for indigent defense funds (including eligible but liable for partial
payment before trial):
Divide Line C by two (2) and enter results ...... > Line D $
-125.00
Round result of Line D down to the nearest $5.00 value and if the amount is greater than zero (0)
enter this amount on the “NOTIFICATION OF ELIGIBILITY, APPOINTMENT OF COUNSEL,
NOTIFICATION OF LIABILITY & REPAYMENT ORDER” as the “First payment due” (See instruction
manual for instructions on filling out NE-NFL).
NHJB-2313-DFSSup (07/01/2013)
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