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IN THE IOWA DISTRICT COURT FOR IN THE (State of Iowa - OCIO)

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Rev. 1/6/12
IN THE IOWA DISTRICT COURT FOR
____________________________ COUNTY (JUVENILE DIVISION)
IN THE INTEREST OF
___________________________,
Child(ren).
)
)
)
)
)
)
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Juvenile No. ____________________________
FINANCIAL AFFIDAVIT OF PARENT
AND APPLICATION FOR APPOINTMENT
OF COUNSEL/ FOR
Child Parent Other: ___________
In support of my application for appointment of counsel, and under penalty of perjury, the undersigned states:
Name: _______________________________________________________ Birth Date: ________________________
Home Phone: ____________________ Cell Phone: __________________ E-mail: ___________________________
Street Address: ___________________________________________________________________________________
Street/P.O. Box Apt # City State Zip
Case: CINA TPR Del Other: _________ Relationship to Child: Parent Other: __________
Do you have a job? No Job Yes, Full Time Yes, Part Time (List Hours/week: __________________)
Who do you work for? ____________________________________________
How much money do you currently make before taxes or deductions? __________ per hour month year
How much money have you made in the last 12 months from any source, before taxes or deductions? ______________
How many family members are supported by or live with you? _______
If a spouse lives with you, how much money does your spouse make? __________ per hour month year
List all other money you, or anyone else living in your household, has coming in: ______________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List what you own including money in banks, cars, trucks, other vehicles, land, houses, buildings, cash, or anything
else worth more than $100: _________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List amounts you pay monthly for mortgages, rent, car loans, credit cards, child support, any other debts: ___________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I understand I may be required to repay the State for my attorney fees and costs and those of my child, I may be
required to sign a wage assignment, and I must report any changes in the information submitted on this
financial affidavit. I promise under penalty of perjury that the statements I make in this application are true
and that I am unable to pay for an attorney to represent me.
Date_________________ Signature ____________________________________________
Rev. 1/6/12
IN THE IOWA DISTRICT COURT FOR
____________________________ COUNTY (JUVENILE DIVISION)
IN THE INTEREST OF
___________________________,
Child(ren).
)
)
)
)
)
)
Juvenile No. ____________________________
ORDER OF APPOINTMENT
OF COUNSEL FOR
Child Parent Other: ___________
NOW on this ________ day of _____________, 20___, the Court having received and examined the Financial
Affidavit of Parent and Application for Appointment of Counsel and having considered not only the Child/Applicant’s
income, but also the availability of any assets subject to execution and the seriousness of the charge or nature of the
case, finds the following:
1. The Child/Applicant:
Is eligible
1
for court-appointed counsel pursuant to Iowa Code § 815.9 because:
Child/Applicant’s income is at or below 125% of the poverty guidelines and Child/Applicant
is unable to pay for the cost of an attorney; OR
Child/Applicant’s income is between 125% and 200% of the poverty guidelines and not
appointing counsel would cause Child/Applicant substantial financial hardship; OR
Child/Applicant’s Income is over 200% of the poverty guidelines, case is a felony-level
delinquency, and not appointing counsel would cause Child/Applicant substantial financial
hardship.
Is a child and is otherwise eligible for court-appointed counsel under Chapter 232.
Is not eligible for court-appointed counsel.
2. The counsel/guardian ad litem appointed below to represent the Child/Applicant is:
The local public defender office, nonprofit organization, or attorney designated by the State Public
Defender pursuant to Iowa Code § 13B.4(2) to represent indigent persons in this type of case in this
county OR
An attorney not designated by the State Public Defender, AND any local public defender office or
other designee of the State Public Defender for this type of case in this county has been contacted and
has declined the appointment or withdrawn from the case, or there is no designation for this type of
case in this county, AND the appointed attorney:
Has a current contract with the State Public Defender to represent indigent persons in this type
of case and in this county; OR
Does not have such a contract, but all attorneys with a contract to represent indigent persons in
this type of case in this county have been contacted and no such attorney is available to take
this case; OR
Does not have such a contract, but the State Public Defender has been consulted and consents
to the appointment.
IT IS THEREFORE ORDERED that Child/Applicant’s Application for Appointment of Counsel is
Denied.
Approved, and that __________________________________is appointed to serve as
counsel/guardian ad litem in this case for __________________________________ at State expense
and may be contacted at ________________________.
________________________________
JUDGE, _______ Judicial District
Copy to:
1
NOTE: A different standard applies for determining eligibility for appointment of respondent’s counsel in a Chapter 600A TPR, and additional
findings are required to determine the appropriate party/agency responsible for payment. See Iowa Code §§ 600A.2(11), 600A.6A(2), and 600A.6B.
Do not use this form order for 600A TPR Appointments.
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Completed 29 September 2020

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