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Rule 2.32 – Form 1: Financial Affidavit and Application for Appointment of Counsel

In the Iowa District Court for ______________ County

State of Iowa or _________________________,

)

No. ____________________________

)

Plaintiff/Petitioner,

)

Financial Affidavit and Application for

)

Appointment of Counsel

vs.

)

_______________________________________,

)

Defendant/Respondent.

)

In support of my application for appointment of counsel, and under penalty of perjury, the undersigned states:

Name: _____________________________________________________

Date of birth: ____________________

Home phone: ____________________ Cell phone: __________________ Email: ____________________________

Street address: ___________________________________________________________________________________

Street/P.O. Box

Apt #

City

State

Zip

Pending charges: ______________________________________________________________. In jail?  Yes  No

 No job

 Yes, full time

 Yes, part time (list hours per week: __________________)

Do you have a job?

Who do you work for? ____________________________________________

How much money do you currently make, before taxes or deductions? ____________ per  hour  month  year

How much money have you made in the last 12 months from any source, before taxes or deductions? ______________

How many family members are supported by or live with you? _______

If a spouse lives with you, how much money does your spouse make? ____________ per  hour  month  year

List all other money you, and anyone else living in your household, has coming in: ____________________________

________________________________________________________________________________________________

List what you own, including money in banks, cars, trucks, other vehicles, land, houses, buildings, cash, or anything

else worth more than $100: _________________________________________________________________________

________________________________________________________________________________________________

List amounts you pay monthly for mortgages, rent, car loans, credit cards, child support, and any other debts: _______

________________________________________________________________________________________________

I understand I may be required to repay the state for all or part of my attorney fees and costs, I may be required

to sign a wage assignment, and I must report any changes in the information submitted on this financial

affidavit. I promise under penalty of perjury that the statements I make in this application are true, and that I

am unable to pay for an attorney to represent me.

Date_________________

Signature ____________________________________________

Application For Appointment Of Counsel And Financial Statement Form - Iowa District Court

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