AFFIDAVIT OF INDIGENCEAND

REQUEST FOR COURT APPOINTED COUNSEL

FELONY AND MISDEMEANOR

IMPORTANT: THIS FORM TELLS THE COURT THAT YOU NEED AN ATTORNEY TO REPRESENT YOU ON YOUR PENDING CHARGES, BUT DO NOT HAVE THE MONEY TO HIRE AN ATTORNEY. IF YOU QUALIFY UNDER THE LAW, A JUDGE WILL APPOINT AN ATTORNEY TO REPRESENT YOU IN YOUR CASE. IF YOU DO NOT FILL OUT THE FOLLOWING FORM COMPLETELY AND PROVIDE ALL REQUESTED INFORMATION, IT MAY LEAD TO A DELAY IN PROVIDING YOU WITH A COURT APPOINTED ATTORNEY, EVEN IF YOU QUALIFY UNDER THE LAW. PLEAS READ CAREFULLY AND FILL IN ALL REQUESTED INFORMATION.

NAME: ______

ADDRESS: STREET OR BOX NUMBER ______

CITY: ______

STATE: ______

DO YOU WORK? IF SO, WHERE? ______

IF YOU WORK, HOW MUCH MONEY DO YOU MAKE? ______/WK. ______/MO.

IF YOU ARE MARRIED, DOES YOUR WIFE WORK? YES ______NO______

HOW MUCH DOES YOUR WIFE MAKE? ______/WK. ______/MO.

ARE YOU OR ANY MEMBERS OF YOR FAMILY RECEIVING SOCIAL SECURITY BENEFITS OF ANY KIND? YES ______NO______

WHAT AMOUNT OF SOCIAL SECURITY BENEFITS ARE RECEIVED BY ALL PERSONS IN THE HOUSEHOLD? ______/MO.

DOES ANY MEMBER OF THE HOUSEHOLD RECEIVE ANY OTHER PAYMENTS SUCH AS RETIREMENT, UNEMPLOYMENT OR FOOD STAMPS? YES ______NO______| ______/MO.

WHAT IS THE TOTAL AMOUNT OF SALARY OR ANY OTHER TYPE OF BENEFITS THAT IS RECEIVED BY ALL PERSONS RESIDING IN THE HOUSEHOLD FROM ALL SOURCES? ______/MO.

DO YOU HAVE A CHECKING ACCOUNT OR SAVINGS ACCOUNT? YES ______NO______

HOW MUCH MONEY DO YOU HAVE IN ANY OR ALL BANK ACCOUNTS? ______

DO YOU OWN YOUR OWN HOME? YES ______NO______

HOW MUCH IS PAID MONTHLY IN MORTGAGE OR RENT? ______/MO.

LIST ALL PERSONS CURRENTLY LIVING WITH YOU:

NAME / AGE / RELATIONSHIP

IF YOU PAY THE FOLLOWING MONTHLY BILLS, INDICATE THE AMOUNT:

ELECTRICITY: / GAS: / WATER:
TELEPHONE: / AUTOMOBILE: / INSURANCE:
CREDIT CARDS:

DO YOU PAY CHILD SUPPORT? IF SO, HOW MUCH? ______/MO.

LIST ANY OTHER DEBTS THAT YOU PAY ON A REGULAR BASIS:

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LIST ALL AMOUNTS OWED TO BANKS, CREDIT UNIONS OR OTHER LENDING INSTITUTIONS:

______

WHAT IS THE VALUE OF PERSONAL PROPERTY THAT YOU OWN? ______(EXAMPLE: CARS, BOATS, RARE COLLECTIONS, FURNITURE, ETC.)

DO YOU OWN ANY STOCK, BONDS, OR OTHER SECURITIES? YES ______NO______IF YES, STATE THE VALUE: ______

HAVE YOU POSTED BAIL/BOND? YES ______NO______

IF YES, DID YOU HIRE A BONDSMAN? YES ______NO______

IF YOU HIRED A BONDSMAN, HOW MUCH HAVE YOU PAID ON YOUR BOND? ______HOW MUCH DO YOU OWE THE BONDSMAN? ______

I CERTIFY THE ABOVE FINANCIAL AFFIDAVIT TO BE CORRECT AND FURTHER CERTIFY THAT I HAVE BEEN ADVISED OF MY RIGHT TO HAVE REPRESANTATION BY COUNSEL IN THE TRIAL OF THE CHARGES PENDING AGAINST ME AND THAT I AM WITHOUT MEANS TO EMPLOY COUNSEL OF MY OWN CHOOSING AND HEREBY REQUEST THE COURT TO APPOINT COUNSEL FORME.

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DEFENDANT’S SIGNATURE

BEFORE ME THE UNDERSIGNED NOTARY PUBLIC, ON THIS ______DAY OF ______, 20____, PERSONALLY APPEARED THE ABOVE NAMED DEFENDANT WHO SUBSCRIBED THE FOREGOING INSTRUMENT, AND AFTER HAVING BEEN DULY SWORN, STATED UPON HIS/HER OATH THAT THE FOREGOING STATEMENT IS TRUEAND CORRECT.

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NOTARY PUBLIC FOR THE STATE OF TEXAS