Application For Appointed Defense Services (Page 3 of 4) in pdf

10.

Do you currently have any other court cases pending in the District, in which you already have counsel

appointed?

Yes

If yes, give attorney=s name __________________________________________________

(Check One)

D E P E N DE N TS

MONTHLY BILLS

SING LE

TOTA L NUM BER ______________

RENT /HOU SE PAY MEN T _________

MARRIED

L IS T N AM E , A G ES A N D

FOOD /CLOTHING _______________

R E LA T IO N S H IP T O YO U

WIDOWED

UTILITIES _____________________

______________________________

S E PA R A TE D /

ALIMONY _____________________

DIVORCED

______________________________

CHILD SUP POR T _______________

______________________________

INSTALLMENT PAYM ENTS

______________________________

___________________________

OTH ER PAY MEN TS _____________

TOTA L PAYM ENTS _____________

I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorized the STATE OF

KANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings and any other asset

balances that are needed to process this affidavit with the district court. Further authorize the STATE OF KANSAS to

order a consumer credit report and verify other credit information, including past and present mortgage and landlord

references.

Executed this _________ day of ________________________, ________.

__________________________________________

Signature

__________________________________________________________________________________

FOR JUDGE=S USE ONLY

Determination o f Eligibility - K.A.R. 105 -4-1(b ): AAn eligible

indigent defendant is a person whose combined household income

and liquid assets equal less than the sum of the defendant=s

reasonable and necessary living expenses plus the anticipated cost of

private legal representation.@

APPOINTMENT DENIED

PUBLIC DEFENDER APPOINTED

ATTORNEY APPOINTED

APPLICATION FEE OF $100 TO B E COLLECT ED IMM EDIATELY AS A COND ITION OF RELEASE

(K.S.A. 22-4529, 2003 H.B. 2121 effective May 1, 2003)

PARTIALLY INDIGENT, ABLE TO PAY $_________________

____________________________________

JUDGE

2002 Poverty Guidelines for 48 Contiguous States & the Guidelines for estimated copy of private legal reprensation

District of Co lumbia

Size o f Family Unit

Poverty Guideline

Security level

Nondrug C ost

Drug C ost

Application For Appointed Defense Services Page 3

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