USE INK PENS ONLY - NO PENCILS ANSWER ALL QUESTIONS

BOOK-IN #______

DECLARATION OF INABILITY TO HIRE COUNSEL

AND REQUEST FOR COURT-APPOINTED COUNSEL

“I STATE, UNDER OATH AND SUBJECT TO BEING CHARGED WITH PERJURY, THAT THE FOLLOWING

ANSWERS TO THE FOLLOWING QUESTIONS ARE TRUE. I AM ASKING FOR COURT-APPOINTED COUNSEL.”

  1. What is your full legal name? ______

What are the street address, town, state, and zip code where you live or stay? (MUST LIST ADDRESS)

______

What is your date of birth? ______

  1. Are you a U. S. citizen? ______If you answered “No” to this last question, what is your country of citizenship? ______
  2. What is the telephone number where you live?______What is your cell phone number?______
  3. Who pays for the house or apartment where you live? ______How is this person related to you?______How much do they pay each month?$______How many people live in the house or apartment where you live?______About how much money do all the adults that you live with make together each month?$______
  4. Do you have any children? ______How many? _____Do your children live with you? _____Do you get child support?______How much each month?$______If your children do not live with you, do you pay child support?______How much each month? $______
  5. Do you have a job?______Where do you work? ______How much do you get paid? $______per ______(mo./wk./hour). How many hours do you work per week?______
  6. If you don’t work right now, when is the last time you had job?______Where did you work? ______When is the last time you got paid?______How much?$______
  7. Do you get any welfare, disability, pension or unemployment benefits?______What kind?______Total each month? $______
  8. Do you own a car ,truck or a motorcycle?______Which ?______Is it (are they) paid for?______How much is it (are they) worth? $______
  9. Do you own a house or any land?______Which?______Is it paid for?______What is it worth? $______
  10. Do you have any cash anywhere?______How much?______Do you have any bank accounts?______

How much money do you have in the bank?______.

  1. Are you in jail?______How much is your bond?______Can you make your bond?______. Can anyone else make your bond?______Who?______If you have already made bond, who is your bondsman?______

How much are you paying your bondsman?$______each month/week?

  1. Was anybody else charged with this offense with you?______Who? ______

I HEREBY AUTHORIZE THE COURT ADMINISTRATOR TO VERIFY THIS INFORMATION FROM ANY SOURCE.

______

Defendant’s Signature

SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority, on , 20 .

______

Notary Public/Magistrate

Commission Expires:______

EXHIBIT A

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