Indigent Defense – Confidential Application for an Attorney Step 1 of 4 25% CONFIDENTIAL APPLICATION FOR APPOINTED COUNSEL AFFIDAVIT OF INDIGENCY READ ME FIRST: (1) Please fill out as much of this form as you can; if you do not have exact numbers, please estimate financial amounts as accurately as possible. (2) If you do not know an answer, please type DO NOT KNOW. (3) All financial information needs to be current as of the date you’re filling out this form. For example, if you think you’re getting hired next week for a job but today you’re still not working, you should list that you’re unemployed.SECTION 1 - Personal InformationName(Required) First Last Date of Birth(Required) Month Day Year Marital Status(Required) Single Separated Married Divorced Widowed Mailing Address(Required) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Alternate PhoneEmail(Required) Gender(Required) Woman Man Transgender Non-Binary/Gender Non-Conforming Prefer not to respond Do you reside with anyone?(Required) Yes No Please list their name(s) and relation(s) Add RemovePlease use one line per personDo you live in Kent County?(Required) Yes No For how long have you resided in the county? Number of children(Required) Number of dependents you support(Required) Type of case for which you need an attorney(Required) Criminal PPO Violation Other Please specify your case type Case Number(Required) Judge(Required) Court(Required) Date of Next Hearing(Required) Month Day Year Time of Next Hearing(Required) Hours : Minutes AM PM Are you currently in jail?(Required) Yes No Check any/all of the below that apply I am under the age of 18. I receive public assistance (SSI, SSD, Medicaid, WIC, Food Stamps, Live in Sect. 8, etc.). I am currently serving a sentence in jail or prison. I am currently receiving residential treatment in a mental health or substance abuse facility. I am currently homeless. **IF YOU CHECKED ANY OF THE LINES ABOVE, SKIP TO SECTION 4 – CASE INFORMATION** SECTION 2 - Employment InformationAre you currently employed? Yes No Name of Employer Position/Job Title How long have you worked with this employer? Weekly Take Home EarningsWhen were you last regularly employed? MM slash DD slash YYYY Is your spouse employed? Yes No I don't have a spouse Name of Spouse's Employer Spouse's Weekly Take Home EarningsDo you receive/have you applied for employment comp, welfare, ADC, Social Security benefits, and/or worker's comp? Yes No Amount Received SECTION 3 - Financial InformationDo you have any of the following account(s)? Checking Savings Retirement None of these How much money is in the account(s)?Please list account type next to amount Add RemoveDo you own a vehicle? Yes No Estimated value of vehicleAmount owed to bank/creditorPlease list any other property or assets that you own(i.e., property, land, other vehicles, boat, stocks, funds, etc.)Please list all debts and their monthly cost(s)(i.e., credit cards, child support payments, loans, court ordered fines/costs, medical bills, etc.)What is your current living situation? Own a home Rent an apartment/home Live with a roommate Live with family Live alone What is the value of your home?Amount owed to the bank SECTION 4 - Case InformationAre you on bond?(Required) Yes No Bond AmountDo you have other pending cases? Yes No Please list current pending cases Add RemoveHave you ever had an appointed attorney/public defender before?(Required) Yes No Attorney Name Date of Counsel Appointment Month Day Year By signing below, I affirm/swear that everything I have written in this form is true and accurate to the best of my belief. I understand that I may be required to show verification of the information provided above. Applicant Digital Signature(Required) Today's Date(Required) Month Day Year YOU MAY BE REQUIRED TO REIMBURSE ON A PAYMENT SCHEDULE FOR AN APPOINTED ATTORNEY
