Affidavit Of Indigency Application For Counsel (Page 2 of 3) in pdf

Affidavit Of Indigency Application For Counsel Page 2

List by name, age and relationship to you, any persons who are dependent upon you for support.

Indicate beside each how much you contribute toward their support.

NAME

AGE

RELATIONSHIP

AMOUNT OF SUPPORT

Have you received within the past twelve months any money from any of the following

sources?

a. Business, profession or form of self-employment?

Yes

b. Rent payments, interest or dividends?

Yes

c. Pensions, annuities or life insurance payments?

Yes

d. Gifts or inheritances?

Yes

e. Any other sources?

Yes

If the answer to any of the above is “yes”, describe each source of money and state the amount

received from each during the past twelve months.

SOURCE OF MONEY

AMOUNT

Do you own cash, or do you have any money in a checking or savings account?

Yes

If the answer is “yes”, state the total amount of the cash owned.

__________________________

Do you own any real estate, stocks, bonds, notes, or other valuable property (excluding

ordinary household furnishings and clothing)?

Yes

If the answer is “yes”, describe the property and state the appropriate value of the items owned.

________________________________________________________________________________

What kind of motor vehicle do you own?

___________________________________________

Is it paid for?

Yes

If not, what are the payments? ______________________________________________________

How much do you owe (on liens, mortgages, other encumbrances or debts)? _______________

____________________________________________________________________________________

SCACRVIFORM02GS (02/2009)

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Affidavit Of Indigency Application For Counsel Page 2