USE PENS ONLY - NO PENCILS ANSWER ALL QUESTIONS

BOOK-IN #______

UNSWORN DECLARATION OF INABILITY TO HIRE COUNSEL

AND REQUEST FOR COURT-APPOINTEDCOUNSEL

(For use by inmates only)

  1. What is your full legal name? ______

What is the street address, town, state, and zip code where you live or stay?(MUST LIST ADDRESS)______

______What is your date of birth? ______

  1. Are you a U. S. citizen?______If you answered “No” to this last question, what is your country of citizenship?______
  2. What is the telephone number where you live or stay?______What is your cell phone number?______
  3. Who pays for the place where you live or stay? ______How is this person related to you?______How much do they pay each month?$______How many people live in the place where you live?______About how much money do all the adults that you live with make together each month?$______
  4. Do you have any children? ______How many?_____Do your children live with you?_____Do you get child support?______How much each month?$______If your children do not live with you, do you pay child support?______How much each month? $______
  5. Do you have a job?______Where do you work? ______How much do you get paid? $______per (mo./wk./hr.) if paid per hr. how many hrs. do you work per wk.______.
  6. If you don’t work right now, when is the last time you had job?______Where did you work? ______When is the last time you got paid?______How much?______
  7. Do you get any welfare, disability, pension or unemployment benefits?______What kind?______

Total each month? $______

  1. Do you own a car, truck or motorcycle?______Which ?______Is it (are they) paid for?______

How much is it (are they) worth? $______

  1. Do you own a house or any land?______Which?______Is it paid for?______What is it worth? $______
  2. Do you have any cash anywhere?______How much? $______Do you have any bank accounts?______

How much money do you have in the bank? $______

  1. Are you in jail?______How much is your bond? $______Can you make your bond?______

Can anyone else make your bond?______Who?______If you have already made bond, who is your bondsman?______How much are you paying your bondsman? $______ea. mo./wk.

  1. Was anybody else charged with this offense with you?______Who? ______

I HEREBY AUTHORIZE THE COURT ADMINISTRATOR TO VERIFY THIS INFORMATION FROM ANY SOURCE.

“My name is ______. My date of birth is ______.

My inmate identifying number, if any, is ______. I am presently incarcerated in the Wichita County Jail in Wichita County, Texas.I DECLARE UNDER PENALTY OF PERJURY that the foregoing is true and correct.”

Executed the ______day of ______, ______.

______

DECLARANT

______I DECLINE TO COMPLETE THIS APPLICATION ______(Defendant’s initials)

EXHIBIT A-1 REVISED 6-26-17