Defendants Financial Affidavit printable pdf download

DEFENDANT’S FINANCIAL AFFIDAVIT

Case Number _______________ Offense: _____________________________ Bond $____________________

My name is _________________________________.

I am fully competent to make this

affidavit. I certify that I am financially unable to employ counsel and I hereby request the

Court to appoint counsel.

I am providing the following information as part of my

application for a court appointed attorney. I fully understand that every question in this

form must be answered and that failure to do so could result in the application for counsel

not being considered.

1. Full legal name: _________________________________________ Home Telephone # :________________

2. Address: _______________________________________________ How long at this address? ___________

(house number, street, apt #, City, State)

3. Social Security Number: __________________________ TDL: ___________________________________

4. Other names I have used: ___________________________________________________________________

5. Age: _____________ Date of Birth: ________________ Place of Birth: ___________________________

6. Relationship of those persons who live with me and who are dependent upon me for support:

Relationship ________________

Age _______

Relationship ________________

Age _______

Relationship ________________

Age _______

Relationship ________________

Age _______

7. Number of years married to a person listed above: ____________________________

8. I live in: House, apartment, condominium: _________________ Renting or Buying __________________

9. Job or occupation: __________________________________________ How long: ______________________

10. Employer’s Name: _________________________________________________________________________

11. Employer’s Address: _______________________________________ Work Telephone #_________________

12. Supervisor’s Name: ________________________________________________________________________

13. If unemployed, my last job was: _______________________________Date employment ended: ___________

INCOME

14. My average TOTAL monthly income .........................................................................

$ ____________

15. Average TOTAL income of spouse ..............................................................................

$ ____________

16. List all other sources of income received by you or your spouse not considered in questions 14 and 15

Amount $ ________________________ from _______________________

ASSETS

17. Total of cash on hand, checking accounts, savings accounts, certificates of deposit,

stocks, mutual funds, life insurance policies, etc… .....................................................

$ ____________

18. Value of real estate owned less amount owed (other than family residence) ................

$ ____________

19. Value of automobiles less amount owed .......................................................................

$ ____________

TOTAL VALUE OF 17 thru 19 ........................................................................................

$ ____________

DEFENDANT’S FINANCIAL AFFIDAVIT

Page 1 of 2

Defendants Financial Affidavit

Related Articles

Related forms

Related Categories