Court-Appointed Counsel Form

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CAUSE NO. _______________________
New Charge: _________________________________
Immed. Capias: _______________________________
Revocation: __________________________________
THE STATE OF TEXAS
IN THE JUSTICE COURT
VS.
PCT. # _____________
____________________________________
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/Assets (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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