Taylor County APPLICATION FOR COURT APPOINTED ATTORNEY (Affidavit of Indigence)

(Criminal Cases)

1. CASE#______OFFENSE:______Taylor County. S.O. # ______

2. CASE#______OFFENSE:______

3. CASE#______OFFENSE:______

4. CASE#______OFFENSE:______

5. CASE#______OFFENSE:______

My Full legal name is: ______Other names I have used:______

My age is: _____ My D.O.B is: ____/____/_____ My DL # is: ______State ____. I SPEAK ENGLISH (Check One) YES ___ or NO ___

Names of Spouse & Children. Also List Any Other Persons Residing in Your Current Household:

Name / Relationship / Age / Name / Relationship / Age
1. / 5.
2. / 6.
3. / 7.
4. / 8.

I live at: ______(Street) in ______(City) in ____ (State) ______(Zip Code) House, Apt, Condo.

My phone # is: (_____) ______My alternate phone number is (_____) ______(circle one above)

I am (Check One) ____ Employed. Or, I am ____ NOT employed. My employer’s name is: ______

My employer’s address is: ______My work phone # is (_____)______

Other Employment info: ______

Are you currently receiving? (Check all that apply) / MY INCOME: Which I receive MONTHLY / AMOUNTS
___ Food Stamps ____TANF / Take Home Pay (Income)
___ Medicaid ____SSI / Spouse, fiancé, partner (Income)
____Public Housing ____Social Security / Investment Income
EXPENSES: I HAVE EACH MONTH / PAYMENTS / Rental Income
Rent or Mortgage Payment / Pension Payments
Vehicle(s) Payment(s) / Unemployment Benefits
Insurance (Homeowner’s, Life, Health, Vehicle, Dental) / Social Security Benefits
Child Care / Child Support
Child Support, which YOU PAY / TANF
Electricity, Water, Gas, Cable, Satellite TV---Totalà / SSI—Supplemental Security Income
Landline Telephone, cellular phone / Total of Cash you have on hand and/or in a bank account
Food, gasoline, furniture rental / Other monthly incomes (Describe)
Prescriptions or other monthly Medical costs
Monthly Rent-to-Own costs (Furniture, etc.)
Loans (Student, Pay Day) and Debt Payments / TOTAL MONTHLY INCOME
Credit Card Debt (List name of cards) /
$ ______Account Balance: Monthly Paymentà
Probation/Parole Payments
Other Monthly Expenditures (Describe) / (This space for Office use Only)
TOTAL MONTHLY EXPENSES

______

VALUE OF REAL ESTATE I OWN---less the amount I owe is: $______. Value of car(s) I own---less the amount I owe is: $ ______.

I am currently (Check One Box) in jail since: ______or I am out on Bond. (Circle the Type) (Cash) (Personal) (Bondsman) or (CSRP).

I am currently on a MENTAL HEALTH caseload or I have an application pending: (Check one) YES NO

I (Circle One) Have OR Have NOT ATTEMPTED to hire an attorney in this case. Name of Attorney: ______

I understand that any and all information can be verified, and I have authorized the court to do so. “I swear or affirm that the above information and facts I have provided for the court are within my personal knowledge and are true and correct. I understand that if I intentionally or knowingly give false information either in this affidavit or during any hearing on my financial status, that I may be prosecuted for aggravated perjury and if convicted, be sentenced to serve up to ten (10) years in the penitentiary.”

Defendant’s Signature Here ______

SUBSCRIBED and SWORN to before me on this date: (Month) ______on this (Day) _____ and on this (Year) 20____.

DATE RECEIVED: ____/____/______
DATE APPOINTED: ____/____/______
DATE DENIED: ____/____/______
ATTORNEY: ______
______
JUDGE’S SIGNATURE / IDC SIGNATURE:

______(Official’s Signature Here)

Indigent Defense Official Court Administrator

Deputy District Clerk Court Bailiff/Deputy Constable

Notary Public Magistrate

(Revised October 2017, DWW, SM)