Free Affidavit for Appointed Defense Services in PDF - Kansas

APPLICATION FOR APPOINTED DEFENSE SERVICES (To acc omp any Financial Affidavit) STATE VS. _______________________________ DISTRICT COURT CASE NO. _____________ Or IN RE:____________________________________ COUNT Y _____________________________ NOTICE TO APPLICANT: ANY DEFEND ANT CHA RGED W ITH A FELONY VIOLA TION, ENTITLED TO AN A TTORNEY PU RSUANT TO K.S.A. 22-4503, IS REQUIRED BY LAW TO PAY A $100 BOARD OF INDIGENTS DEFENSE SERVICES APPLICATION FEE, UNLESS THE FEE IS WAIVED BY THE COURT. THE FEE IS TO BE PAID TO THE CLERK OF THE DISTRICT COURT. FAILURE TO PAY THIS FEE MAY BE CONSIDERED A VIOLATION OF THE CONDITIONS OF YOUR RELEASE AND YO UR BON D M AY BE REVO KED FOR FAILURE TO PAY SAID APPLICATION FEE. A. GENERAL INFORMATION 1. The information on the attached affidavit is not co nfidential. 2. Any information contained on the attached affidavit may be verified by the judge or the Kansas B oard of Indigents= Defense S ervices. 3. False entries may lead to criminal prosecution and conviction. 4. If you do not understand a specific question or need help, ask for assistance. 5. The judge may place you under oath and inquire further about any information provided on this form. B. ELIGIBILITY FOR DEFENSE SERVICES 1. Appointed counsel and other defense services will only by provided to people who cannot afford to pay for these service s themselves. 2. If the judge determines that you are able to pa y a part of the co sts of your defense, you will be found p artially indigent and the court will order yo u to pay for a part of these costs. 3. If, after the date o f the alleged offense, you tra nsfer any of your property for less than it is worth, the State may sue to obtain repayment of the cost of your defense. 4. You must inform the court if there is a change in any of the financial information given on the affidavit. C. REPAYM ENT TO THE STATE

K.S.A. 1997 Supp. 21-4603 provides that persons who are convicted of a crime must reimburse the state general fund for all or part of the attorney fees and expenses paid by the Ka nsas State Bo ard of Indigents= Defense Services. K.S.A. 1997 Supp. 21-4610 also provides that persons who are placed on probation or whose sentence is suspended must, as a condition of probation, reimburse the state general fund for all or part of the attorney fees and expenses paid by the Kansas State Board of Indigents= Defen se Services. The cou rt shall take into account the financial reso urces and the nature of the b urden that pa yment of such sum will impose. Any person who has been required to pay such sum and who is not willfully in default may petition the sentencing court to waive paym ent of an y remaining ba lance or po rtion thereof. I have read or have had read to me and understand the above notice. I hereby request that court-appointed counsel be prov ided tom e and agree to attem pt to rep ay the State fo r the costs of my d efense if the court so order s.

________________________ Date

__________________________________________ Signature of D efendant

FIN AN CIA L A FFIDA VIT 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. Name ______________________________ Age____ D.O.B. _________Phone ____________ S.S.#___________ Address ____________________________ City ___________________ State _____________ Zip 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? __________________________________________________________ 2. List the places you have worked in the last six months: 1. Name ______________________________ Address _____________________________________ 2. Name ______________________________ Address _____________________________________ 3. Name ______________________________ Address _____________________________________ If employed, give an approximate monthly rate of pay ________________________________________ Is your spouse Self-Employed Employed Unemployed

3. 4.

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? ___________________________________________________________ 5. Do you own a car, truck or motorcycle? Yes No

If yes, give year, make and model: ________________________________________________________ Please give value _______________ Is it paid for? Yes No Amount owing _________________ 6. Do you receive, or have you received, in the past six month, income from rental property, public assistance, support, or other sources, including from a business? Yes No If yes, give source and monthly income: ___________________________________________________ 7. Do you have any money or cash in savings, checking accounts or other funds? Yes No If yes, list amount of money available to you _______________________________________________ 8. 9. Do you own a home, land or other property? Yes No If yes, give value _________________ No

Can you afford to pay anything toward the costs of your defense at this time? Yes

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 __________________________________________________

(Check One) SING LE MARRIED WIDOWED

D E P E N DE N TS TOTA L NUM BER ______________ L IS T N AM E , A G ES A N D R E LA T IO N S H IP T O YO U ______________________________

MONTHLY BILLS RENT /HOU SE PAY MEN T _________ FOOD /CLOTHING _______________ UTILITIES _____________________ ALIMONY _____________________

S E PA R A TE D / DIVORCED

______________________________ CHILD SUP POR T _______________ ______________________________ ______________________________ INSTALLMENT PAYM ENTS ___________________________ OTH ER PAY MEN TS _____________ TOTA L PAYM ENTS _____________

I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorized 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. 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 ________________________, ________.

__________________________________________ Signature __________________________________________________________________________________ FOR JUDGE=S USE ONLY Determination o f Eligibility - K.A.R. 105 -4-1(b ): AAn 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.@




APPOINTMENT DENIED PUBLIC DEFENDER APPOINTED ATTORNEY APPOINTED APPLICATION FEE OF $100 TO B E COLLECT ED IMM EDIATELY AS A COND ITION OF RELEASE (K.S.A. 22-4529, 2003 H.B. 2121 effective May 1, 2003) PARTIALLY INDIGENT, ABLE TO PAY $_________________



____________________________________ JUDGE

2002 Poverty Guidelines for 48 Contiguous States & the Guidelines for estimated copy of private legal reprensation District of Co lumbia Size o f Family Unit Poverty Guideline Security level Nondrug C ost Drug C ost

1 $ 8,860 2 $11,940 3 $15,020 4 $18,100 5 $21,180 For family units with more than 5 members, add $3,080 for each additional member

Off-G rid 1 2 3 5 6 7 8 9 10

$6,000 $7,158 $5,168 $4,542 $2,340 $2,964 $4,330 $2,524 $1,754 $2,640

$3,060 $4,334 $3,368 $2,324