DC-099 (Rev. 12/2021) Page 2 of 2
Applicant:
Case #(s):
AFFIDAVIT OF INDIGENCY
I solemnly affirm under the penalty of perjury that all of the information presented above and any
supporting documentation, to the best of my knowledge and belief, is true and accurate in support of
my inability to hire a private attorney or my inability to pay for private home detention monitoring. By
signing below, I acknowledge that I have applied for eligibility for representation by the Office of the Public
Defender and/or for the Private Home Detention Monitoring Program and I agree to pay any applicable fees
under Maryland State Regulations by the Office of the Public Defender or otherwise required by State Law.
AUTHORIZATION FOR RELEASE OF INFORMATION
As permitted by MD Code, Criminal Procedure Article 16-210(e)(3)(i), I hereby consent and authorize the
Comptroller of Maryland to provide to the Office of the Director of Commissioners of the District Court (“the
Office”) or its designee income information from my Maryland income tax return filed for the tax year
immediately preceding the year in which this authorization is executed. I further consent and authorize the
Office or its designee to use such income information for the sole purpose of determining whether I qualify for
the services of the Office of the Public Defender to assist me in a legal matter and/or for eligibility under the
Home Detention Monitoring Program.
INFORMED CONSENT RELEASE
1. As permitted by § 8-625(d)(1) of the Labor and Employment Article, Annotated Code of Maryland and by
federal regulations under 20 C.F.R. part 603, this signed form releases certain confidentiality rights of the
undersigned.
2. This consent form will remain in effect until the District Court Commissioner’s obligation to maintain these
records for its files has terminated, revocation by the undersigned, or five (5) years.
3. Please include all other names you have used for the period of time the records are requested:
4. Please provide the undersigned individual’s SOCIAL SECURITY NUMBER:
5. The undersigned acknowledges that this signed form permits access to confidential information maintained
by the Maryland Department of Labor, Division of Unemployment Insurance. This information includes
wage history, employment history, and the number and amount of Unemployment Insurance benefits
received by the undersigned.
6. The undersigned individual consents to the Office of the District Court Commissioner or its designee to
review confidential information, including benefits information and wages earned by the individual and
reported by his or her employer for purposes of evaluating the individual’s qualification for a Court -
appointed attorney. The determining of whether the undersigned qualifies for a Court-appointed attorney
may assist the undersigned in a legal matter.
7. The confidential information will be disclosed only to the Office of the District Court Commissioner or its
designee. The information disclosed pursuant to this release will be used only for the purposes stated in
this release, which is to determine whether the undersigned qualifies for representation by the Office of the
Public Defender to assist the undersigned in a legal matter.
Source Annual Total Federal Povert
Guidelines
Income $ Household Size
ssets $ FPG
Expenses $ Cost to Hire $
Net Income $
Date
Signature of Applicant
Date
Signature of Consenting Individual (Applicant)
