Free jc81.p65 - Michigan

Approved, SCAO

JIS CODE: RFC

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

REQUEST AND ORDER FOR COURT APPOINTED APPELLATE COUNSEL

CASE NO. PETITION NO.

Court telephone no.

1. In the matter of
name(s), alias(es), DOB

REQUEST 2. I,
Name

, declare my intent to appeal from the order entered on in the
Bar no.

Date

Court by .

Hon.

3. I understand I have the right to be represented by an attorney. I am unable to pay fully for the services of an attorney and for the cost of transcripts and have completed the Financial Schedule on the other side of this form. 4. I request an attorney be appointed by the court and the cost of transcripts be waived. I understand I may be ordered to reimburse the court for all or part of the attorney fees and transcript costs. 5. I authorize the court to investigate and obtain any further relevant information from my employer, creditors, the Department of Human Services, the Social Security Administration, and others who have knowledge of my financial circumstances for purposes of aiding the court in determining my eligibility for the appointment of an attorney and waiver of costs of transcripts.

Date Signature Name (please print) Address City, state, and zip Telephone no.

ORDER IT IS ORDERED: 6. The request for appointed counsel is denied because

7. 8.

is appointed to represent the requesting party to conduct an appeal. The court reserves the right to order reimbursement for attorney fees and transcript costs. , court reporter/recorder, R number , shall furnish the transcript required by counsel for these appellate proceedings and the reporter/recorder shall be compensated for the transcripts as provided by law.

9. IT IS FURTHER ORDERED:

Date

Judge

Bar no.

Do not write below this line - For court use only USE NOTE: This form is not to be used for requests and orders for appellate counsel after termination of parental rights. See form JC 84.

JC 81 (11/05)

REQUEST AND ORDER FOR COURT APPOINTED APPELLATE COUNSEL

MCR 3.915(B)

Complete this Financial Schedule if you are seeking a court-appointed attorney. FINANCIAL SCHEDULE
1. RESIDENCE Rent 2. MARITAL STATUS Single 3. INCOME Married Divorced Separated
b. Length of employment

Own

Live with parents

Room/Board

Dependents:

Number

a. Employer name and address

c. Average of pay

weekly Gross: $

monthly Net: $

every two weeks

d. Other income State monthly amount and source, such as DHS, VA, rent, pensions, spouse, unemployment, child support, etc.

4. ASSETS

State value of car, home, bank deposits, bonds, stocks, etc.

5. OBLIGATIONS

Itemize monthly rent, installment payments, mortgage payments, child support, etc.

6. REIMBURSEMENT

I understand that I may be ordered to reimburse the court for all or part of my attorney and defense costs.

I declare under penalty of contempt of court that the above information is true to the best of my information, knowledge, and belief.
Date Signature