INCARCERATED ☐yes ☐no ICE Hold ☐yes ☐no Citizenship: ☐yes ☐no Primary Language:
AFFIDAVIT IN SUPPORT OF COURT APPOINTED ATTORNEY
Answer every question completely. If the question does not apply to you, place a N/A in the blank. Incomplete applications will be denied. If you
need assistance, notify the person in charge of taking this application. If you are incarcerated, you MUST provide supporting documents (payroll
stubs, proof of government assistance and other supporting documentation to your first court appearance. A finding of indigence will not be
determined without supporting documentation.
County Where Case is Pending
Personal Information:
Last name: First Name: Middle:
Mailing Address:
Phone No. Date of Birth: Place of Birth
Employer: Hourly Rate: Hours Per Week:
Do you have friends or relatives from which you can borrow money for an attorney? ☐yes ☐no
Do you own any property that you could sell or use as collateral? ☐yes ☐no If yes, approximate value: $
If unemployed, explain how you pay for basic necessities.
Size of Family Unit (Members of immediate family that you have a legal obligation to financially support).
☐yes ☐no
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Stocks, Bond, Investments
Jewelry, Firearms, Collectibles
I have been advised of my right to representation for the charge(s) pending against me. I certify that I am unable to employ counsel of my own
choosing and I hereby request the court to appoint counsel for me. I swear that the above information is true and correct. The information I listed is
accurate and I will immediately notify the court, in writing, of any changes in my financial situation. ALL INFORMATION IS SUBJECT TO
VERIFICATION. FALSIFICATION OF INFORMATION IS A CRIMINAL OFFENSE.
Defendant’s Signature: Date:
Received by Deputy/Staff: Date:
☐ Defendant stated he wanted to apply for court appointed counsel. However, defendant ☐refused to complete the application ☐was unable to
complete the application due to ☐language ☐ other: Explain
click to sign
signature
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