Free CP-410 - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of: ) ) ) ) ) ) ) ) )

A minor under 18 years of age. Date of birth:

CASE NO. REQUEST FOR APPOINTED ATTORNEY

We request that the court appoint an attorney to represent (name) .

STATEMENT OF FINANCIAL RESPONSIBILITY We understand that if we are able to pay for some legal services, the court may order us to pay. We also understand that we must pay the State of Alaska for any help given by the Alaska Public Defender Agency or other appointed attorney if it is decided we were not entitled to the assistance. CHILD'S FINANCIAL STATEMENT Fill in this section only if you are requesting an attorney to represent a child. Child's Name Address Date of Birth

I.

CHILD'S INCOME INFORMATION (after taxes, but before other deductions) a. Income during last 12 months: Wages Welfare Child Support Payments Social Security Payments Pension/Trust Fund Payments Other Total Income

$

Page 1 of 5 CP-410 (1/06)(cs) REQUEST FOR APPOINTED ATTORNEY

Del.R. 16, CINA R.12 AS 47.10.050, AS 47.12.090

In the Matter of: II.

Case No. $

CHILD'S ASSETS Cash on hand (savings or other accounts) Where Land owned Acres and Location Motor Vehicles Number, year, model Securities Stocks, bonds, notes Life Insurance Life Insurance case values/dividends Snowmachines, boats, motors, etc. Collectibles (stamps, coins, antiques) Guns Precious metals/stones Electronic Equipment (computers, TV's, etc.) Permanent Fund Money Received Total Assets

PARENTS' FINANCIAL STATEMENT

This section must be filled in if you are requesting an attorney to represent either a child or parents. FATHER'S NAME Address Present Employer How Long? (If not employed, give last employer and date terminated.) (If employed less than one year, give previous employer.) Employer Address Employer Phone # ***** MOTHER'S NAME Address Present Employer How Long? (If not employed, give last employer and date terminated.) (If employed less than one year, give previous employer.)
Page 2 of 5 CP-410 (1/06)(cs) REQUEST FOR APPOINTED ATTORNEY Del.R. 16, CINA R.12 AS 47.10.050, AS 47.10.090

Phone # Date of Birth

Phone # Date of Birth

In the Matter of: Employer Address Employer Phone #

Case No.

I. a.

PARENTS' INCOME INFORMATION (after taxes, but before other deductions). Income during last 12 months. Father Wages Welfare Unemployment Pension or trust Child Support Contributions Social Security Other Total Income $ Mother

B.

Current Monthly Income: Father's Income Source: Mother's Income Source:

II.

PARENTS' ASSETS - Present Value Father Cash (checking and savings accounts) $ Land, buildings, mobile homes Acres and Location Motor Vehicles Number, year, model Securities: Stocks, bonds, mutual funds Businesses Snowmachines, boats, motors, etc. Guns Collectibles (stamps, coins, antiques) Jewelry (other than wedding rings) Life Insurance cash value/dividends Pension plans/annuities Permanent Fund Money Received Household goods Electronic equipment (TV's, computers, etc.) Total Assets Mother

III.

PARENTS' DEBTS Father Mortgages $
Del.R. 16, CINA R.12 AS 47.10.050, AS 47.10.090

Mother

Page 3 of 5 CP-410 (1/06)(cs) REQUEST FOR APPOINTED ATTORNEY

In the Matter of: Loans Doctor or hospital bills Charge card bills IV. Total Debts MONTHLY EXPENSES Food Rent Utilities Car payments Furniture & TV payments Child support or alimony Loans/Time payments Total Expenses

Case No.

$

V.

DEPENDENTS: Name Age Relationship

*****

GENERAL WAIVER We authorize anyone, including our past employers, to give to the Alaska Court System all information about any income source we have had for the past three years since an appointed attorney represented us in our first court appearance. We understand that this information may be given to the Attorney General, if requested after the end of our case. We declare, under oath, that we have read or have had read to us the Statement of Financial Responsibility and the General Waiver. We further declare that this financial statement is true. We understand that if we give false information in the Financial Statement we may be prosecuted for perjury under AS 11.56.200.

Date Date Date
Page 4 of 5 CP-410 (1/06)(cs) REQUEST FOR APPOINTED ATTORNEY

Child's Signature Father's Signature Mother's Signature
Del.R. 16, CINA R.12 AS 47.10.050, AS 47.10.090

In the Matter of:

Case No.

Subscribed and sworn to or affirmed before me at on . (date) (SEAL) SUMMARY (To be filled out by court) Clerk/Notary Public

, Alaska,

Child Assets Liabilities Available Assets Value For Delinquency matters, what charges have been filed against the child?

Father

Mother

Page 5 of 5 CP-410 (1/06)(cs) REQUEST FOR APPOINTED ATTORNEY

Del.R. 16, CINA R.12 AS 47.10.050, AS 47.10.090