Free Financial Statement, Affidavit of Indigence, Request for Counsel and Order - Kentucky

AOC-350 Rev. 5-09 Page 1 of 3

Doc. Code: AI & 0I
COMM
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EA L TH OF KE
lex et justitia

Case No._______________________ Court_________________________ County________________________

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UCKY

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Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS Chapter 31

OF JUS

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FINANCIAL STATEMENT, AFFIDAVIT OF INDIGENCY, REQUEST FOR COUNSEL AND ORDER (CRIMINAL CASES)

Name: ________________________________________________________________

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Address:__________________________________________________________________________________________ Telephone: (______) _______________________ Charges:____________________________________________

_________________________________________________________________________________________________ FINANCIAL STATEMENT: 1. Income: Employed? [ ] Yes If Yes: [ ] Full-time Income from Employment: [ ] monthly

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Age: _____________________

[ ] No [ ] Part-time [ ] biweekly [ ] Temporary/Seasonal Length of Employment: ___________ [ ] hourly $_______________

If No, date last employed: _____________________________ Married? [ ] Yes [ ] No If Yes, Spouse's Income from Employment: If Yes, Spouse Employed? [ ] monthly [ ] biweekly [ ] Yes [ ] No [ ] hourly $________________

Total Income from ALL other source(s) and amount received per month: [ ] Welfare: $__________ [ ] Food Stamps:$ ___________ [ ] Social Security/Disability:$____________ [ ] Worker's Comp: $________ [ ] Unemployment:$____________ [ ] Retirement:$____________ [ ] Child Support/Maintenance: $__________ [ ] Stocks, Trusts, Bonds:$______________ [ ] Child Care Assistance: $___________________ [ ] Other : __________________ Total Income from ALL other source(s): $ _______________________ 2. TOTAL MONTHLY INCOME: $________________________ Property: Own Real Estate? [ ] Yes [ ] No If Yes, Value of Real Estate: $_________________ Amount owed : $_______________ Own Mobile Home? [ ] Yes [ ] No If Yes, Value of Mobile Home: $_________________ Amount owed : $_______________ Own Personal Property: Motor Vehicles in Operable Condition (including motor cycles, riding lawn mowers, ATVs, etc.): Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Make/Model Year:__________ Value: $_____________ Amount Owed:$_________________ Bank Accounts: [ ] Yes [ ] No If Yes, total balance of all accounts: $________________________ Other Asset(s) (i.e., boat, jewelry, cash) Asset type: _________________ Value: $ _________________ Amount owed: $_______________ Asset type: _________________ Value: $ _________________ Amount owed: $_______________

AOC-350 Rev. 5-09 Page 2 of 3 3.

Doc. Code: AI & 0I

Dependents:

[ ] Yes

[ ] No

If Yes, Number of Dependent(s) (including children, elderly, or disabled): _____________ Relationship of dependent(s):____________ Age(s) of Dependent(s)_______________ 4. Monthly Expenditures: Mortgage payment/ Rent: [ ] Yes [ ] If Yes, amount of payment: Child support obligation: [ ] Yes [ ] If Yes, amount of payment:

No $_________________________________ No $_________________________________

Other out-of-pocket monthly bills (FOR HOUSEHOLD): [ ] utilities: $_________ [ ] water: $ _________ [ ] telephone service (land or cell): $ _________ [ ] internet service: $_________ [ ] cable/satellite: $_________ [ ] car payment: $___________ [ ] credit card payments: $_________ [ ] car / health/home owners/ renters insurance payments: $________ [ ] unreimbursed childcare: $_________ [ ] tuition: $_________ [ ] medical debts: $_________ [ ] student loan payments: $_________ [ ] Other Financial Obligations: $ _____________ Total of other out-of-pocket monthly bills: TOTAL MONTHLY EXPENDITURES: 5. Cash bond posted: $_______________________________ $_______________________________

[ ] Yes [ ] No If Yes, amount of bond: $________________________ Posted by (Name of Surety): _______________________________________________

Request for Appointment of Counsel: I state to the Court that: (1) I am not now represented by an attorney and (2) I am without sufficient financial means or assets to afford a private attorney; or (3) I have retained or intend to retain private counsel. _________________________________ Name of Counsel PERJURY WARNING: I understand that knowingly making any false statement in this Financial Statement, Affidavit of Indigency and Request for Appointment of Counsel will subject me to the penalties for perjury as contained in KRS Chapter 532, exposing me to a maximum sentence of five (5) years imprisonment. I declare under the penalty of perjury that I have read or have had read to me the above Financial Statement, Affidavit of Indigency and Request for Appointment of Counsel and that the information contained within is true, complete, and accurate to the best of my knowledge. ___________________________________________ Affiant's Signature ____________________________ Date

Being sworn to tell the truth, I certify that the facts and information stated in the above Financial Statement, Affidavit of Indigency and Request for Appointment of Counsel are true, complete, and accurate to the best of my knowledge. I also further swear to timely inform the Court of any significant changes in any of the information in the above Affidavit of Indigency. _____________________________________________ Affiant's Signature ______________________________________________ Signature/Title of Officer Administering Oath ____________________________ Date ____________________________ Date

AOC-350 Rev. 5-09 Page 3 of 3

Doc. Code: AI & 0I
COMM
O
NW

EA L TH OF KE
lex et justitia

Case No._______________________ Court_________________________ County________________________

NT

UCKY

Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS Chapter 31

RT

OF JUS

TI

FINANCIAL STATEMENT; AFFIDAVIT OF INDIGENCY; REQUEST FOR COUNSEL; AND ORDER (CRIMINAL CASES)

ORDER
Based upon the above attested statements, IT IS HEREBY ORDERED: 1. The Affiant, _________________________________________________________________________, [ ] is NOT indigent pursuant to KRS Chapter 31 and the Request for Appointment of Counsel is DENIED. [ ] is indigent pursuant to KRS Chapter 31 and the Request for Appointment of Counsel is GRANTED. The Court appoints the Department of Public Advocacy to represent the Defendant in the above-styled case. 2. A partial fee for representation [ ] is NOT assessed. [ ] is assessed in the amount of $ _______________ to be paid in full no later than the ____________ day of ____________________________, 2________. [ ] may be reserved for a later date.

DATE: _________________, 2_______

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_____________________________________________ JUDGE _____________________________________________ District/Circuit (Circle one) Division ________

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