Affidavit Of Inability To Employ Counsel - Order Of Appointment Form printable pdf download

AFFIDAVIT OF INABILITY TO EMPLOY COUNSEL; ORDER OF APPOINTMENT

CAUSE NO: ____________

THE STATE OF TEXAS

IN THE JUVENILE COURT

VS.

_________M.B.____________________

DeWITT COUNTY, TEXAS

BEFORE ME, the undersigned authority, on this day personally appeared the parent/guardian of the child named

herein, who, after being by me duly sworn by penalty of perjury, on oath deposes and says as follows: “I am the

parent/guardian of the child in the above entitled and numbered cause. I certify that I cannot afford to hire a

lawyer and request the court appoint a lawyer for said child. I declare the following information concerning

my resources is true and correct”:

Mother’s Employer: ______________________________Employer’s Address:_____________________________

Father’s Employer: _______________________________Employer’sAddress:_____________________________

HOUSEHOLD INCOME:

Mother’s Take Home Pay:

$__________ Weekly

$__________Bi-weekly

$__________Monthly

Father’s 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:

________________________________________________

Parent/Guardian Signature

Sworn to and subscribed before me, on this the ______ day of _______________, 2012, witness my hand and seal

of office.

____________________________________________

County Clerk of DeWitt County

By: ______________________________ Deputy Clerk

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.

____________________________________________

Parent/Guardian Signature

Affidavit Of Inability To Employ Counsel - Order Of Appointment Form

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