Application For Appointed Defense Services Page 2
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4FIN AN CIA L A FFIDA VIT
For court-appointed attorney, expert or other services
)
(K.A.R . 105-4-3
Judicial Dist. ________________
County ____________________
Case No. _____________
FALSE STATEMENTS COULD RESULT IN ANOTHER CASE BEING FILED AGAINST YOU.
Name ______________________________ Age____ D.O.B. _________Phone ____________ S.S.#___________
Address ____________________________ City ___________________ State _____________ Zip Code _______
Spouse (If married-including common-law)__________________________________________________________
1.
Are you
Self-Employed
Employed
Unemployed
If self-employed, what line of work? _____________________________________________________
If employed, who do you work for? ______________________________________________________
If unemployed, for how long? __________________________________________________________
2.
List the places you have worked in the last six months:
1. Name ______________________________ Address _____________________________________
2. Name ______________________________ Address _____________________________________
3. Name ______________________________ Address _____________________________________
3.
If employed, give an approximate monthly rate of pay ________________________________________
4.
Is your spouse
Self-Employed
Employed
Unemployed
If self-employed, what line of work? ______________________________________________________
If employed, who does he/she work for?___________________________________________________
If employed, give an approximate monthly rate of pay ________________________________________
If unemployed, for how long? ___________________________________________________________
5.
Do you own a car, truck or motorcycle?
Yes
No
If yes, give year, make and model: ________________________________________________________
Please give value _______________ Is it paid for?
Yes
No Amount owing _________________
6.
Do you receive, or have you received, in the past six month, income from rental property, public assistance,
support, or other sources, including from a business?
Yes
No
If yes, give source and monthly income: ___________________________________________________
7.
Do you have any money or cash in savings, checking accounts or other funds?
Yes
No
If yes, list amount of money available to you _______________________________________________
8.
Do you own a home, land or other property?
Yes
No
If yes, give value _________________
9.
Can you afford to pay anything toward the costs of your defense at this time?
Yes
No
If yes, how much _____________________________________________________________________
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