Free Financial Statement, Affidavit of Indigence, Request for Counsel and Order (DNA/TPR Cases) - Kentucky

DNA-11 Doc. Code: AICO 01/9/2007 11:47 am Rev. 5-05 Ver. 1.01 Page 1 of 2 Commonwealth of Kentucky Court of Justice www.kycourts.net KRS Chapter 31; KRS 620.100; KRS 625.0405; KRS 625.080

Case No. _________________ FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCE, REQUEST FOR COUNSEL AND ORDER (DNA/TPR Cases) Court County Division [ ] District [ ] Circuit _________________ _________________

IN THE INTEREST OF: _________________________________________________________________, A CHILD
PARENT OR PERSON EXERCISING CUSTODIAL CONTROL MUST PROVIDE THE FOLLOWING INFORMATION: NAME: ______________________________________________________________________________________________________ ADDRESS:___________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SSN: _____________________________ DOB: ____________________________ Telephone: ( ) _____________________ (mm/dd/yyyy) Area code + number

[ ] The above-named parent is an unemancipated minor (under the age of 18) and I am his/her parent or legal guardian_____________________________________________________________________________________
(Name of Parent or Legal Guardian of Minor Parent)

FINANCIAL STATEMENT (This information should be provided by the parent or person exercising custodial control of the above-named child, OR if the child's parent is an unemancipated minor, the adult parent or legal guardian of the unemancipated minor should provide the information) 1. 3. 5. 6. 7. 9. Are you employed? [ ] Yes [ ] No 2. If "Yes," are you [ ] Full time; [ ] Part time; or [ ]Seasonal/Temporary

How many adults are living in your household? ____ 4. How many children are living in your household? _____ Total Household Income Per Month: Available Cash from ALL SOURCES (bank accts, TANF, SSI, SSD, W/C, etc.) Cash value of other resources (food stamps, WIC, etc.) Property Ownership: [ ] Yes [ ] No Property Value: $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ [ ] Yes [ ] No Monthly Total: $_________________

10. Number of autos you own that are in working order: ______ Total Value: 11 Total Value of All Other Assets: 12. Total Debts: 13. Child support obligation?

14. Other obligations ________________________________________________________________________ 15. Number of dependents: ____________

REQUEST FOR THE APPOINTMENT OF LEGAL COUNSEL: I state to the court that: (1) [ [ [ (2) (3) ] ] ] I am a parent who exercises custodial control or supervision of the above-named child; I am a nonparent who exercises custodial control or supervision, of the above-named child; I am a parent who is a party to a termination of parental rights action.

I am not now represented by legal counsel; and I am without sufficient monetary means or assets to afford private legal representation.

DNA-11 Rev. 5-05 Page 2 of 2 AFFIDAVIT OF INDIGENCE PERJURY WARNING I understand that making a false statement in the Financial Statement, Affidavit of Indigence and Request for Appointment of Counsel may subject me to the penalties for perjury as contained in KRS Chapter 532. The maximum sentence for perjury is five (5) years imprisonment. I declare under the penalty of perjury that I have read or have had read to me the information contained on this form and that the statements provided here are true, complete and accurate to the best of my personal knowledge. _______________________________ Date _____________________________________ Affiant's Signature _____________________________________ Affiant's Name (Print or Type)

SUBSCRIBED AND SWORN TO before me this _____ day of _________________, 2________. My Commission Expires: _____________________ ______________________________________
Attesting Officer or Notary's Signature

ORDER Based on this application/motion, IT IS HEREBY ORDERED: 1. The applicant, or legal guardian/parent of the applicant: [ [ 2. ] is NOT deemed indigent under KRS Chapter 31. ] IS found to be indigent under KRS Chapter 31.

APPOINTMENT OF COUNSEL [ [ ] is DENIED. ] is GRANTED.

The Court, having determined that the applicant is a needy person as defined in KRS 31.110 and that, pursuant to KRS Chapter 620, further proceedings regarding the above-named child are required, or that the applicant is a party to a termination of parental rights proceeding, DOES HEREBY APPOINT the Hon. ______________________________________ to represent the applicant. Counsel's fee, fixed by the Court at the appropriate statutory amount, shall be paid by the Finance and Administration Cabinet pursuant to KRS 620.100. ______________________ Date _________________________________ Judge's Signature _________________________________ Judge's Name (print or type)

Copy Distribution: Court File, Applicant, Appointed Counsel

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