Arraignment and Advice of Rights

Financial Affidavit
Full Name:*

First NameMiddle NameLast NameSuffix
Cell Phone Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Case # / Ticket #*

State of Michigan - 35th District Court

Petition for Appointed Attorney
To request an Appointed Attorney you must complete this entire form. All information must be provided by the defendant and must be current, accurate and true. Be advised, intentionally or knowingly giving false information may result in your prosecution for the offense of perjury.

Based upon the Federal Poverty Guidelines, as determined by the Department of Health and Human Services (DHHS), if the Court determines that you can afford an attorney, the Court is entitled to deny your request for an Appointed Attorney, or you may be ordered to pay the Court back a portion of the attorney fees as determined by the DHHS guidelines. Any payment you may be required to make under the guidelines shall only be ordered if you are convicted and/or take a plea to an offense.
Marital Status*

SingleMarriedDivorcedSeparated
Residence*

RentOwnLive with parentsRoom/Board
Number of Dependents:*
Are you a student?*

YesNo
School you are attending*
Number of Credit Hours*
Employment and Income
Currently Employed*

YesNoOn Temporary Lay-Off or Shutdown
Date Lay-off/Shutdown Began:*

MonthDayYear
Expected Return Date

MonthDayYear
Date of Last Employment:*

MonthDayYear
Previous Employer Name *
Length of Employment *
Employer Name *
Length of Employment*
Employer Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Average Take-Home Pay*
Monthly Take Home Pay Employer #1
Time frame for take-home pay:*

WeeklyEvery 2 weeksMonthlyYearly
Do you work a second job?*

YesNo
Employer Name #2*
Length of Employment*
Employer Address #2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Average Take-Home Pay #2*
Monthly Take Home Pay Employer #2
Time frame for take-home pay:*

WeeklyEvery 2 weeksMonthlyYearly
Do you have other income such as spouse's income, pension payments, unemployment payments, etc?*

YesNo

Total Other Income
Total Monthly Income
Public Assistance: If you are receiving Public Assistance, you are presumed to qualify for an Appointed Attorney. If you are currently receiving any of the below, check ALL that apply:*

NoneFood Assistance (Food Stamps, Bridge Card, SNAP)MedicaidPublic HousingTemporary Assistance to Needy Families (TANF)Supplemental Security Income (SSI)VA / Veteran's BenefitsOther
Assets
Do you have cash on hand or money in savings or checking accounts?*

YesNo
Total $ Amount for Cash/Savings/Checking *
Do you own any vehicles such as auto, recreational or watercraft?*

YesNo
Description of Vehicles (Make, Model and Year)*
Total $ Value of Vehicles*
Do you have any other assets such as a home, business, retirement accounts, stock, bonds or other valuable property?*

YesNo

Total Assets

	Monthly Amount
Unemployment Payments
Pension Payments
Spouse's Income
Rental Property Income
All Other Income

	Estimated Value
Your Residence (If owned)
Additional Properties (if owned)
Businesses (if owned)
Retirement Accounts
Any other assets

Monthly Expenses *

	Estimated Amount of Payment
Rent/Mortgage
Autombiles (Combined)
Insurance (life, health, auto, homeowners, etc.)
Recreational Vehicles, Watercraft, etc (Combined)
Transportation (gas, bus fare, etc.)
Utilities (Electric/ Gas (Heat)/ Water)
Monthly Cell/Phone Bill
Cable/ Satellite TV/ Internet
Child Support / Alimony
Child care
Food
Clothes
Medical
Education
Loans and Credit Card Debt
All Other Expenses

Total Monthly Expenses
I have been advised of my right to representation by counsel to defend me as to the charge(s) pending against me. I am without means to employ counsel of my own choosing, and hereby request an Appointed Attorney. By signing my name below, I swear that all of the above information about my financial condition is current, accurate and true to the best of my information, knowledge and belief. I further understand and have been advised that based upon the Federal Poverty Guidelines determined by the Department of Health and Human Services, and published for review upon the Court’s website, if the Court determines that I can afford an attorney, the Court is entitled to deny my request for an Appointed Attorney, or I may be ordered to pay the Court back a portion of the attorney fees as determined by the guidelines. I have been informed that any payment I may be required to make under the guidelines shall only be ordered if I am convicted and/or take a plea to an offense.
Applicant's Signature

Clear

By clicking on submit, you confirm that the information given in this form is true, complete and accurate. A copy of your completed forms will be sent to 35th District Court. In addition, you will receive a confirmation email which includes a copy of your completed forms.

If you have any questions, call the Court at 734-459-4740.
Court Email
example@example.com
Should be Empty:

Financial Affidavit

State of Michigan - 35th District Court

Employment and Income

Assets