Free AFFIDAVIT: ELIGIBILITY FOR APPOINTED OR PUBLIC DEFENDER COUNSEL (SCA-C&M101) - West Virginia

WEST VIRGINIA PUBLIC DEFENDER SERVICES

AFFIDAVIT: ELIGIBILITY FOR APPOINTED OR PUBLIC DEFENDER COUNSEL
NAME: ADDRESS: CONTACT PHONE: DATE OF BIRTH: SOCIAL SEC. #
CASE NO.(S) COURT? MAGISTRATE CIRCUIT

COUNTY

SUPREME

CHARGE(S): CASE TYPE-SPECIFY: FELONY
ABUSE & NEG BOND AMOUNT: DO YOU PLAN TO HIRE PRIVATE COUNSEL? YES NO RESULT: MISDEMEANOR EXTRADITION PROBATION REVOC CONTEMPT JUVENILE OTHER-SPECIFY YES NO NO MENTAL HYGIENE

WERE YOU ABLE TO MAKE BOND?

HAVE YOU TRIED TO HIRE PRIVATE COUNSEL? YES

GROSS MONTHLY INCOME from ALL sources: Employer
Self-employment Benefits Alimony/Child Support Received Annuities ; ODD JOBS ; Public Assistance ; Disability Benefits (Worker s Comp/VA/Social Security) ; Pensions

; Spouse s Employment; ; Food Stamps

; 2 Job ; Unemployment ; Social Security/SSI;

nd

; ; ;

; Rental Income OTHER (Specify):

; Interest

; Dividends

;

MONTHLY TOTAL FROM ALL SOURCES NAMES OF DEPENDENTS SUPPORTED BY YOU: LAST NAME FIRST NAME 1. 2. 3. 4. 5. 6. TOTAL ASSETS: Cash $
Vehicle ; Checking/Savings Accounts $ Monies Owed to You $

$

RELATIONSHIP

AGE

DISABILITIES

TOTAL NO. OF DEPENDENTS YOU SUPPORT

; Tax Refunds Due $

Value of Real Estate (other than your residence) $ ; Stocks $ Rent/Mortgage $ ; Bonds

; Vehicles: Model/Year ; Notes $ ; Car Payment $ ; OTHER?

,
$ ; Loan Payments $

; Spouse s

TOTAL MONTHLY EXPENSES:
child care/health care) $ (Medical Bills/Car/Home Repairs) $

;

Utilities (gas/elect/phone/water/sewage/heat) $ ; Alimony $

; Job-Related Expenses (uniform/transportation/protective equipment/insurance premiums/ ; Child Support $ ; Other One-Time Debts You Currently Owe

. WARNINGS!

TOTAL EXPENSES

$

(1) False Swearing May Result in Criminal Prosecution (2) The Information In This Affidavit is NOT Confidential and May Be Made Available to Other Persons!

I understand that by Court Order as a condition of probation or otherwise, I may be held responsible for repayment of court costs and the cost of my attorney to the extent determined to be reasonable in relation to my financial circumstances, and that such court order will become a valid judgment against me until paid.
DATE: Taken, subscribed, and sworn or affirmed before me by SIGNATURE: this County, WV. day of

,

, in

NOTARY PUBLIC/MAGISTRATE/AUTHORIZED COURT PERSONNEL W.Va. Code § 29-21-16 SCA-C&M101/7-96