Free Financial Affidavit to Accompany Application in .pdf (Acrobat) - Kansas


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State: Kansas
Category: Court Forms - State
Author: bhelm
Word Count: 574 Words, 3,950 Characters
Page Size: 595 x 842 pts (A4)
URL

http://165.201.69.209/forms/07forms/finaff_08_07.pdf

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FINANCIAL AFFIDAVIT
For Court-Appointed Attorney, Expert or Other Services (K.A.R. 105-4-3) Judicial Dist. County CASE NO. FALSE STATEMENTS COULD RESULT IN ANOTHER CASE BEING FILED AGAINST YOU!! Birth Year

FOR CLERK'S USE ONLY

Name Address

Age City

Phone State

S.S.# xxx-xxZip Code

Spouse (If married ­ including common-law) 1. Are you Self-Employed Employed Unemployed

If self-employed, what line of work? If employed, who do you work for? If unemployed, for how long? Are you receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 2. List the places you have worked in the last six months: 1. 2. 3. 3. 4. Name Name Name Address Address Address

If employed, give an approximate monthly rate of pay Is your spouse Self-Employed Employed Unemployed

If self-employed, what line of work? If employed, who does he/she work for? If employed, give an approximate monthly rate of pay If unemployed, for how long? Is he/she receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 5. Do you own a car, truck, or motorcycle? If yes, give year, make and model: 1. 2. Please give value 6. Is it paid for? Yes No Amount owing Yes No

Do you receive, or have you received, in the past six months, income from rental property, public assistance, support, alimony, maintenance, or other sources, including from a business? If yes, give source and monthly income: Yes No

7.

Do you have money or cash in savings, checking accounts or other funds? If yes, list amount of money available to you

Yes

No

8. 9.

Do you own a home, land, or other property?

Yes

No If yes, give value Yes No

Can you afford to pay anything toward the costs of your defense at this time? If yes, how much

10.

Do you currently have any other court cases pending in the District, in which you already have counsel appointed? Yes No

If yes, give attorney's name

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(Check One) SINGLE MARRIED WIDOWED SEPARATED/DIVORCED

DEPENDANTS TOTAL NUMBER LIST NAMES, AGES AND RELATIONSHIP TO YOU

MONTHLY BILLS RENT/HOUSE PAYMENT FOOD/CLOTHING UTILITIES ALIMONY/MAINTENANCE CHILD SUPPORT INSTALLMENT PAYMENTS OTHER PAYMENTS TOTAL PAYMENTS

I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorize the STATE OF KANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings, and any other asset balances that are needed to process this affidavit with the district court. I further authorize the STATE OF KANSAS to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references. Executed this day of , 20 .
____________________________________________________

Signature of Applicant FOR JUDGE'S USE ONLY
DETERMINATION OF ELIGIBILITY ­ K.A.R. 105-4-1(b): "An eligible indigent defendant is a person whose combined household income and liquid assets equal less than the sum of the defendant's reasonable and necessary living expenses plus the anticipated cost of private legal representation."

TO BE COLLECTED PURSUANT TO K.S.A. 22-4529: APPLICATION FEE OF $100 effective 7/1/04

Estimate of anticipated cost of private legal representation: APPOINTMENT DENIED PARTIALLY INDIGENT, ABLE TO PAY $ PUBLIC DEFENDER APPOINTED ATTORNEY APPOINTED

Applicable poverty guideline level:

Judge

2007 Poverty Guidelines for the 48 Contiguous States & the District of Columbia
Size of Family Unit Poverty Guideline

1......................................................$ 10,210 2......................................................$ 13,690 3......................................................$ 17,170 4......................................................$ 20,650 5......................................................$ 24,130 For family units with more than 5 members, add $3,480 for each additional member.
Revised 06/08/07

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