Affadavit Of Indigency Parent Attorney Form (Page 2 of 4) in pdf

16. All my income from all sources including, but not limited to (circle if applicable: wages, interest, gifts, AFDC, SSI, social security,

retirement, disability, pension, unemployment, alimony, worker’s compensation, child support, food stamps, SSD, etc.):

$ _________________________________ per ___________________from_________________________________________

17. All money available to me from any source: (A) Cash: _________________________________(B) Checking, savings, or CD account(s)

give bank, account number, balance:________________________________________________________________________________

_____________________________________________________________________________________________________________

(D) Credit card(s) – give account number, balance, credit limit, and type (Visa, Master Card, etc.):_______________________________

_____________________________________________________________________________________________________________

E) Other: ______________________________________________________________________________________________________

18. All vehicles/vessels owned by me, solely or jointly, within the last six (6) months (including, but not limited to, cars, trucks, motorcycles,

farm equipment, boats, etc.):

________________________________________ value $________________________ amount owed $___________________

19. All real estate owned by me, solely or jointly, within the last six (6) months (including land, lots, houses, mobile homes, etc.):

________________________________________ value $________________________ amount owed $___________________

20. All other assets or property owned within the last six (6) months or expected in the future:

________________________________________ value $________________________ amount owed $___________________

________________________________________ value $________________________ amount owed $__________________

21. The last income tax return I filed was for the year _______________ and it reflected a net income of $___________________. I will file

a copy of my tax return within one week, if required.

22. I am out of jail on bond of $_____________________________made by __________________________________________.

The money to make bond, $____________________________ was paid by _________________________________________.

PART III

23. Acknowledging that I am still under oath, I certify that I have listed in Parts I and II all assets in which I hold or expect to hold any legal

or equitable interest.

24. I am financially unable to obtain the assistance of a lawyer and request the Court to appoint a lawyer for me. If this application is for a

Pauper’s Oath, I assert that I am unable to pay the required filing fee.

25. I understand that it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months, 29 days, or be fined up to $2,500,

or both, if I intentionally or knowingly misrepresent, falsify, or withhold any information required in this affidavit. I also understand that I

may be required by the Court to produce other information in support of my request for an attorney.

This the ______ day of _____________________, 20____.

_________________________________________________.

(Movant)

Sworn to and subscribed before me this the _____ day of ______________________, 20__. ______________________________________

Judge/Clerk/Deputy Clerk

Affadavit Of Indigency Parent Attorney Form Page 2