Free Finanical Affidavit and Application for Court Appointed Counsel - New Hampshire


File Size: 140.3 kB
Pages: 4
Date: August 26, 2008
File Format: PDF
State: New Hampshire
Category: Court Forms - Federal
Author: NHJB
Word Count: 1,036 Words, 6,971 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.courts.state.nh.us/forms/nhjb-2313-ds.pdf

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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL
RSA:

Check Case Type:

Homicide Misdemeanor

Felony (Non Homicide) Juvenile Other

Misdemeanor Appeal Supreme Court Appeal

This form must be filled out completely. If an item does not apply to you enter N/A. In this affidavit & application you will swear that all the information is correct and state "I understand that I may be required to repay the services provided me by court appointed counsel unless the court finds that I am or will be financially unable to pay." Name: Address: Telephone: Marital Status Single Date of Birth: Married Divorced Age Separated Widowed Soc. Sec. No:

List dependents you personally support: (Include address if not same as yours. List relationship & age) a. b. c. d. YOURS (A) $ $ $ $ $ $ $ $ $ $ $ $ $ $ SPOUSES (B)

1. AVAILABLE MONEY a. Cash on Hand .............................................................. b. Checking Accounts ...................................................... c. Savings Accounts ........................................................ d. Stock, Bonds, Trusts, CD's, Other (CSVLI etc.) .......... TOTALS 1: 2. INCOME a. Salary/Wages ­ Take home pay (weekly b. Alimony or Maintenance Received (weekly c. Child Support Received (weekly 3. EMPLOYMENT YOURS a. Employer: b. Address: Full Time Check:
x 4.333=) x 4.333=)

$ $ x 4.333=) $ $ SPOUSES

TOTALS 2:

Part Time

Seasonal

Full Time

Part Time

Seasonal

4. HOUSING COSTS a. Monthly Rent or Mortgage ........................................................................... $ b. Utilities (Electricity, heat, etc) ....................................................................... $ TOTALS 4: ................................. $
NHJB-2313-DS (10/31/2006) Page 1 of 4

Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL

5. MONTHLY LOAN PAYMENTS (List only loans and regular payments not listed elsewhere. NOT for monthly
living expenses.)

Name

Purpose

Still Owe $ $

Monthly Payment $ $

TOTALS 5: ................................. $ 6. OTHER PAYMENTS - Alimony Paid, Child Care, Support Name Purpose Still Owe $ $ Monthly Payment $ $

TOTALS 6: ................................. $ 7. PROPERTY a. Do you own a house or other real estate) Who holds mortgage Yes (if yes, list) No Market Value $ Mortgage Owed $

b. Have you sold or transferred any real estate or personal property worth $200 or more in the last 6 months? Yes (if yes list) No Property To Whom Transferred Value Amount Received $ $ $ $ 8. REMARKS

PLEASE READ THIS CAREFULLY!
Initial each box to show that you have read and understand this application. I request that the court appoint an attorney to represent me in defense of the charges against me as I can not afford to retain private counsel. I understand that if an attorney is appointed to represent me, I shall be liable for all legal fees and any other court approved costs of my defense and will be ordered to repay the state according to my ability which will be determined by the Office of Cost Containment (OCC). I understand that I must contact OCC within 5 days to confirm my mailing address, verify my ability to repay and make ongoing payment and contact arrangements. I understand that if I do not agree with the eligibility findings or ability to repay decisions made by OCC, I may appeal to the court but must prove to the court that any claimed shortage of funds is total or permanent or future employment is unlikely. I understand that I am required to notify the OCC and the court of every change of address while I still owe the state for the cost of my representation. I further understand that if at any time prior to the disposition of my case, my financial condition changes, I must notify the Court and OCC immediately. I swear that the foregoing information and answers are true to the best of my knowledge and are given to induce the state to appoint counsel to represent me because I am currently unable to retain private counsel. I have made the statements on the financial affidavit and understand that I make them under the penalty of perjury the punishment for which is imprisonment for not more than seven years. This has also been explained to me by a court officer.
NHJB-2313-DS (10/31/2006) Page 2 of 4

Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL

AUTHORIZATION FOR THE RELEASE OF INFORMATION To whom it may concern: I hereby authorize the State of New Hampshire, Office of Cost Containment, to obtain any and all information with regard to my employment and financial condition from government agency, bank, creditor or employer.

Date

Applicant Signature

State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any FOR COURT USE

, County of by
Signature of Notarial Officer / Title

Application Approved: If approved this form and NE/NFL required ­ send to OCC. Application Denied: If denied send this form to OCC. NE/NFL not required.

Date

Presiding Justice (Signature required only if application denied)

NHJB-2313-DS (10/31/2006)

Page 3 of 4

Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL

Financial Affidavit Worksheet Enter totals listed on front of form. STEP ONE. Market Value of Property Mortgage Owed 7A. $

7B. (-) $

NET VALUE OF REAL ESTATE ................ > $ If value of real estate is equal to or greater than the amount listed on Financial Eligibility Table (OCC Fm2) then the defendant is "INELIGIBLE" for indigent defense funds. Proceed to next step regardless of results. STEP TWO. Available Money 1A. $

1B. (+) $ Monthly Income 2A. (+) $ 2B. (+) $ TOTAL PART ONE ............................................. > Line A $ Housing Costs Monthly Loan Payments Other Payments Minimum Living Exp (Individual) # Listed Dependents x $100.00 4. $
0.00

5. (+) $ 6. (+) $ (+) $ (+) $ 0.00
250.00

TOTAL PART TWO ............................................ > Line B $ TOTAL FUNDS AVAILABLE FOR REPRESENTATION Line A minus Line B ...... > Line C $

-250.00

If available funds for representation is equal to or greater than the amount listed on Financial Eligibility Table (OCC Fm 2) then the defendant is "INELIGIBLE" for indigent defense funds. See instruction manual. If the defendant is "ELIGIBLE" for indigent defense funds (including eligible but liable for partial payment before trial): Divide Line C by two (2) and enter results ...... > Line D $ Round result of Line D down to the nearest $5.00 value and if the amount is greater than zero (0) enter this amount on the "NOTIFICATION OF ELIGIBILITY, APPOINTMENT OF COUNSEL, NOTIFICATION OF LIABILITY & REPAYMENT ORDER" as the "First payment due" (See instruction manual for instructions on filling out NE-NFL).
NHJB-2313-DS (10/31/2006) Page 4 of 4