Request For Court Appointed Counsel Template
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1REQUEST FOR COURT APPOINTED COUNSEL
CAUSE NO: ____________________
THE STATE OF TEXAS
§
IN THE __________ COURT
VS.
§
OF
_______________________________
§
DeWITT COUNTY, TEXAS
BEFORE ME, the undersigned authority, on this day personally appeared the defendant in this cause who after
being by me duly sworn by penalty of perjury, on oath deposes and says as follows: “I cannot afford to hire a
lawyer and request the court appoint a lawyer for me. I declare the following information concerning my
resources is true and correct”:
REQUIRED: (PRINT CLEARLY – PLEASE PROVIDE CURRENT INFORMATION)
Defendant’s Address:____________________________________________________________________________
Phone Number: ____________________________________________________________________________
Defendant’s Employer: ____________________________Employer’s Address: ________________________
HOUSEHOLD INCOME:
Your Take Home Pay:
$__________ Weekly $__________Bi-weekly
$__________Monthly
Your Spouse/Significant Other:
Take Home Pay:
$__________ Weekly
$_________ Bi-weekly
$__________Monthly
GOVERNMENT BENEFITS: _____ Food Stamps _____ AFDC _____WIC _____SSI _____OTHER (Medicaid)
DEPENDENTS/CHILDREN:
Number of Dependents: ___________ Ages of Dependents/Children: ___________________________________
ASSETS:
Total cash on hand or on deposit anywhere: ________________________________________________________
Property Owned (example: cars, boats, motorcycles, etc.):______________________________________________
EXPENSES (MONTHLY):
Estimate of reasonable monthly living expenses: ____________________________________________________
DEBTS:
Creditor Name(s) and Amount(s): _________________________________________________________________
_____________________________________________________________________________________________
Further affiant sayeth not:
___________________________________________
Defendant’s Signature
Sworn to and subscribed before me, on this the ________ day of _________________________, 20___, witness my
hand and seal of office; at ________________ a.m./p.m.
___________________________________________
JP Pct. # _____/Notary
WAIVER TO RELEASE FINANCIAL/BENEFIT INFORMATION
I, ___________________________________, do hereby authorize persons, organizations, or establishments having
information or records concerning me/us (or) my/our circumstances, to furnish such information to a representative
of the County of DeWitt. I hereby grant permission for the County of DeWitt to obtain information which may have
a bearing on my/our eligibility for assistance. This release form is valid for six months after the date signed.
____________________________________________
Signature
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