Lawrence Legal Aid — Financial Affidavit

Financial Affidavit — Lawrence, Kansas Municipal Court.

To apply for a court-appointed attorney or house arrest/electronic monitoring, please complete this form and upload the supporting documents. If the supporting documents are not submitted your application will not be considered.
Applicant Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Court Case Number(s)
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number(s)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Applying For
Employment Status
Employment status
Employer name
Length of time at job
Nature of work
How long unemployed
Where did you work if unemployed less than 6 months
Monthly SSI/SSDI amount
Dependents

List all your legal dependents.

Rows	Name	Relationship	Age
Name
Name
Name
Name
Name

Household Income
List the gross monthly income for everyone living in your household, including yourself.

Rows	Name	Relationship	Gross Monthly Income
Name
Name
Name
Name
Name

Other sources of income
Assets
Do you have money or cash in savings, checking, stocks/bonds, or other funds?
Amount available to you
Do you own a home, land, or other property?
Value
Assets: List vehicles, RVs, motorcycles, boats owned (Make, Model, Value)
If any property has been transferred since the date of the alleged offense, please provide details
Monthly Expenses
How much do you pay monthly for the following? Leave blank if not applicable.
Rent / House payment
Food
Clothing
Utilities (gas, water, electric)
Technology (phone, internet, cable)
Alimony
Child Support
Loans / Credit Cards
Childcare
Other monthly amount
Proof of Income Uploads
Upload proof of income. You may take photos with your phone if documents aren't digital.
Two most recent pay stubs (if employed)

Cancelof
Benefits award letter (SSI, SSDI, SNAP, TANF, unemployment, etc.)

Cancelof
Most recent bank statement

Cancelof
Most recent tax return (optional)

Cancelof
Any other supporting documentation

Cancelof
Certification & Signature
I certify, under the penalty of perjury, that the foregoing is true and correct. By signing below, I authorize the Lawrence Municipal Court 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 Municipal Court. I further authorize Lawrence Municipal Court to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references.
E-Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Financial Affidavit — Lawrence, Kansas Municipal Court.

Applicant Information

Applying For

Employment Status

Dependents

Household Income

Assets

Monthly Expenses

Proof of Income Uploads

Certification & Signature