APPLICATION REQUESTING APPOINTMENT OF COUNSEL

A parent/guardian must appear and sign this completed form before a Notary in the

Intake Department or Legal Services Department of Travis County Juvenile Court

at 2515 South Congress, Austin, Texas, 78704

For information: (512) 854-7063 Monday thru Friday from 8:00 a.m. – 5:00 p.m.

PID# ______JV# ______

Juvenile Name: ______DOB: ______

Alleged Offense:______Level of Offense: ______

Child in DetentionYes NoBilingual Attorney RequestedYes No

FINANCIAL STATEMENT

Juvenile lives with: Parents Mother Father Legal Guardian Other Adult Person  Foster Care

Number of Persons residing in Home:
NAME / AGE / RELATIONSHIP
TO JUVENILE / RELATIONSHIP TO HEAD OF HOUSEHOLD / MONTHLY INCOME*

* Monthly income is all income sources including employment, child support, food stamps, social security income, any other government assistance. Attach additional names as needed.

TOTAL MONTHLY HOUSEHOLD INCOME ______

On this ______day of ______, 20__, I have been advised by the Juvenile Court of Austin, Travis County, Texas that my child must be representedby an attorney pursuant to Sec. 51.10 of the Texas Family Code. I have been informed that I may have an attorney appointed to represent my child, if I qualify as indigent under Travis County Juvenile Board guidelines. I further understand that if I do not qualify as indigent, then I am responsible for hiring an attorney to represent my child.

I understand that this affidavit is being made under oath, and that it will become part of an official proceeding, and that it is a criminal offense for me to make any false statement in this affidavit and financial statement/questionnaire. By my signature below, I swear that the information I have provided in this application is accurate, true and correct and I will immediately notify the court of any changes in my financial situation. I am unable to hire an attorney and request that an attorney be appointed to represent my child.

 If I do not qualify pursuant to this document, I request a hearing before the judge to present evidence of my inability to hire a lawyer to represent my child.

______

SIGNATUREPRINTED NAME

Address: ______Home Phone ______

Street (Area Code) Number

______Work Phone: ______

City, State Zip(Area Code) Number

STATE OF TEXAS §

COUNTY OF TRAVIS §

Sworn to and Subscribed before me on the ______day of ______20_____.

______

Notary Public in and for the State of Texas

My Commission expires ______, 20____Printed Name ______

Travis County Juvenile Court Review

According to Travis County Juvenile Board Indigency Standards, Applicant:

 Meets Indigent Status

 Does NOT meet Indigent Status

Name of Juvenile Clerk: ______Date of Review: ______

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