APPLICATION FOR APPOINTED DEFENSE SERVICES and FINANCIAL AFFIDAVIT

APPLICATION FOR APPOINTED DEFENSE SERVICES
(to accompany Financial Affidavit)

General Information 1. The information on the attached affidavit is not confidential. 2.The judge or the Kansas Board of Indigents’ Defense Services may verify any information contained on the attached affidavit. 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.

The information on the attached affidavit is not confidential.

Eligibility for Defense Services 1.You will receive an appointed attorney if you meet the standards for indigent status. You may be required to pay an application fee of $100.00 (KSA 22-4529) 2.If the judge determines that you are able to pay a part of the costs of your defense, you will be found partially indigent and the court will order you to pay for a part of these costs. 3.If, after the date of the alleged offense, you transfer 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.

The court shall take into account the financial resources and the nature of the burden that payment 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 payment of any remaining balance or portion thereof.

I have read or have had read to me and understand the above notice. I hereby request that court-appointed counsel be provided to me and agree to repay the State for the costs of my defense if the court so orders.
Date

Month Day Year
Date
Signature *

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FINANCIAL AFFIDAVIT
For Court Appointed Attorney, Expert or other Services
County
District Court Case No.
Full Name
Age
Birth Year
Address
City
State
Zip Code
Phone
Spouse (If married - including common-law)
Household income is defined as your income and the income of all persons who live with you that are related to you by birth or by marriage.
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?
If you are receiving unemployment benefits:
Amount per week
If not, state reason
2. List the places you have worked in the last six months:
Name
Address
2nd Job Name
2nd Job Address
3. If employed, what is your monthly average gross pay?
4. Is your spouse (include common law):

Self-Employed Employed Unemployed
If self employed, what line of work?
If employed, who does he/she work for?
If employed, what is his/her average monthly gross pay?
If unemployed, for how long?
If he/she is receiving unemployment benefits:
Amount?
If, not, state reason
5. Does anyone else live with you, other than your dependants?

Yes No
If yes, list their name, relationship to you, and their income:
Name (1st Person)
Relationship (1st Person)
Gross Monthly Income (1st Person)
Name (2nd Person)
Relationship (2nd Person)
Gross Monthly Income (2nd Person)
Name (3rd Person)
Relationship (3rd Person)
Gross Monthly Income (3rd Person)
6. Do you own a car, truck, or motorcycle?

Yes No
Year (1st vehicle)
Make (1st vehicle)
Model (1st vehicle)
Value (1st vehicle)
Amount Owing (1st vehicle)
Year (2nd vehicle)
Make (2nd vehicle)
Model (2nd vehicle)
Value (2nd vehicle)
Amount Owing (2nd vehicle)
Vehicles worth more than $20,000 are considered liquid asset.
7. Do you receive, or have you received in the past six months, income from rental property, public assistance, support, alimony, maintenance, or other sources, including from a business?

Yes No
If yes, give source and monthly income:
8. Do you have money or cash in savings, checking accounts or other funds?

Yes No
If yes, list amount of money available to you
9. Do you own a home, land, or other property?

Yes No
If yes, give value(s)
10. Have you transferred any property since the date of the alleged crime?

Yes No
If yes, explain
11. Can you afford to pay anything toward the costs of your defense at this time?

Yes No
If yes, how much
12. 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
STATUS:
(Check One)

Single Married (include common law) Widowed Separated/Divorced
Total Number of Dependants:
List names, ages, and relationship of Dependants to you
Monthly Bills:
Rent/House Payment
Food/Clothing
Utilities
Alimony/Maintenance
Child Support
Installment Payments
Other Payments
Total Payments
I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorize 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. I 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 on the following date:
Date

Month Day Year
Date
Signature of Applicant *

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APPLICATION FOR APPOINTED DEFENSE SERVICES

FINANCIAL AFFIDAVIT

For Court Appointed Attorney, Expert or other Services

STATUS: