Free Application for Pro Bono Attorney (Bridgeport) - Connecticut

UNITED STATES BANKRUPTCY COURT DISTRICT OF CONNECTICUT APPLICATION FOR APPOINTMENT OF ATTORNEY ATTORNEYS ARE APPOINTED UNDER THIS COURT'S PRO BONO PROGRAM TO REPRESENT INDIVIDUAL DEBTORS IN CHAPTER 7 AND CHAPTER 13 CASES. IF YOUR APPLICATION FOR THE APPOINTMENT OF AN ATTORNEY IS GRANTED AND IF THE ATTORNEY ASSIGNED TO REPRESENT YOU DETERMINES THAT IT IS IN YOUR BEST INTEREST TO FILE A PETITION UNDER CHAPTER 13 AND A CHAPTER 13 PLAN IS FILED, YOUR ATTORNEY MAY REQUEST THE COURT TO ALLOW A REASONABLE FEE AND REIMBURSEMENT FOR ACTUAL, NECESSARY EXPENSES TO BE PAID OUT OF THAT PLAN. INSTRUCTIONS 1. If this is a joint application (filed by a husband and wife), each must provide all requested information. Please indicate by (H) and (W) if an answer to a particular question only applies to the husband or to the wife. 2. Attach additional sheets of paper if necessary. 3. Return this motion to: Clerk, United States Bankruptcy Court 915 Lafayette Boulevard Bridgeport, CT 06604

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I. Personal/Financial Data

A. State your full name, present mailing address, and a telephone number: _____________________________________________________________________________ _____________________________________________________________________________ B. Do you presently have a pending bankruptcy case? _________________________________ If the answer is yes, state the location of the court _____________________________________ and the bankruptcy case number ___________________________________________________ C. Are you presently employed? __________________________________________________ If the answer is yes, state: (a) the kind of job(s) you have: ______________________________________________ _______________________________________________________________________

(b) the name, address, and telephone number of your employer: _______________________________________________________________________ _______________________________________________________________________ (c) the amount of your usual weekly wages or salary: gross $ _______________; take home pay $___________________ D. Are you self employed? ______________________________________________________ If the answer is yes, state: (a) the kind of work you do: ________________________________________________ (b) the name, address, and telephone number of your business: _____________________ _______________________________________________________________________ _______________________________________________________________________ (c) the amount of your ususal weekly income: gross $________________; take home pay $ ___________________ E. If you are not presently employed or self employed state: (a) the name and address of your last employer: ________________________________ _______________________________________________________________________ _______________________________________________________________________ (b) when you last worked: _________________________________________________ (c) the amount of your last weekly wages, salary, or income: gross $ ________________; take home pay $ ___________________ F. Approximately how much money have you received in the past twelve months from: (a) salary, wages, commissions, and other income: $_____________________________ (b) interest, rent, and investments of any kind: $ ________________________________ (c) gifts, inheritance, and the sale of any property of any kind: (attach itemized list) $ __________________________________ G. Do you have any money in any checking, savings, credit union, or similar accounts? _____________________________________________________________________________ If the answer is yes, state: (a) the name and address of the depository (bank, credit union, etc): _______________________________________________________________________ _______________________________________________________________________ (b) your account number(s): ________________________________________________ (c) the amount of money in each account: $ ____________________________________ H. Is any person, company, or governmental agency holding any money or property which you have a right to demand or receive? _________________________________________________ If the answer is yes, state: (a) the name and address of the person, company, or agency: ______________________ _______________________________________________________________________ (b) the basis for your claim: _______________________________________________

(c) the amount of money and/or a description of the property: _____________________ ______________________________________________________________________ J. Do you own any real estate or other property, excluding household items and clothing: ____________________________________________________________________________ If the answer is yes, describe the property: ____________________________________ ______________________________________________________________________ and state: (a) its location: __________________________________________________________ (b) the approximate present value of each such item of property after deducting the current balance of all mortgages and other liens on that property: __________________ ______________________________________________________________________ K. List each person who depends upon you for support and state your relationship to that person: _____________________________________________________________________________ _____________________________________________________________________________ L. Are there any persons regularly residing in your household who are over the age of eighteen and regularly employed? ________________________________________________________ If the answer is yes, state as to each person: (a) name: ______________________________________________________________ ______________________________________________________________________ (b) relationship to you: ___________________________________________________ ______________________________________________________________________ (c) name and address of employer: __________________________________________ ______________________________________________________________________ M. Itemize all household and living expense per month: (a) rent/mortgage payments: (b) food: (c) utilities: (d) transportation: (e) insurance: (f) other: (g)______________________ (h)______________________ (i)______________________ (j)______________________ Total

$ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________

N. Include any other information which you believe supports your claim that you cannot afford to employ an attorney: __________________________________________________________ _____________________________________________________________________________

II. Efforts to Obtain an Attorney

A. Have you spoken with any attorney about handling your bankruptcy case or any matter arising out of or relating to your bankruptcy case? _____________________________________ If the answer is yes, state: (a) Each attorney's name and address: ________________________________________ _______________________________________________________________________ _______________________________________________________________________ (b) The approximate date you contacted each attorney: ___________________________ _______________________________________________________________________ (c) How (by telephone, in person, etc.): _______________________________________ (d) Reason why attorney was not employed: ___________________________________ _______________________________________________________________________

B. Do you need an attorney who speaks a language other than English? ____________________ If the answer is yes, state the language you speak: _______________________________

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I declare under the penalties of perjury that my answers to the foregoing questions are true to the best of my knowledge. I understand that if I am assigned an attorney and my attorney learns, either from me or elsewhere, that I can afford an attorney, my attorney may give that information to the Court. See Bankruptcy Court Local Rule 1(b) and District Court Local Rule 29(b)(4) and (g). I hereby waive my privileges of attorney/client confidentiality to the extent necessary for my appointed attorney to make an application to be relieved from appointment as provided in District Court Local Rule 29(c) and (d). Dated: ___________________________________ Signature of Applicant ___________________________________ Signature of Applicant _____________________________________________________________________________ Do not write below this line ____________________________________________________________________________

ORDER The Application for Appointment of Attorney is GRANTED/DENIED AND IT IS ORDERED THAT

is appointed to represent the applicant.

Dated:

__________________________________ Alan H.W. Shiff United States Bankruptcy Judge