Arraignment and Advice of Rights

Financial Affidavit
Full Name: *

First Name Middle Name Last Name Suffix
Cell Phone Number *
E-mail *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Case # / Ticket # *

State of Michigan - 35th District Court

Petition for Court Appointed Attorney (CAA)
To request a Court Appointed Attorney (CAA) 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 a CAA, 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 *

Single Married Divorced Separated
Residence *

Rent Own Live with parents Room/Board
Number of Dependents: *
Are you a student? *

Yes No
School you are attending *
Number of Credit Hours *
Employment and Income
Currently Employed *

Yes No On Temporary Lay-Off or Shutdown
Date Lay-off/Shutdown Began: *

Month Day Year
Expected Return Date

Month Day Year
Date of Last Employment: *

Month Day Year
Previous Employer Name *
Length of Employment *
Employer Name *
Length of Employment *
Employer Address *

Street Address

Street Address Line 2

City State / Province

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

Weekly Every 2 weeks Monthly Yearly
Do you work a second job? *

Yes No
Employer Name #2 *
Length of Employment *
Employer Address #2 *

Street Address

Street Address Line 2

City State / Province

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

Weekly Every 2 weeks Monthly Yearly
Do you have other income such as spouse's income, pension payments, unemployment payments, etc? *

Yes No

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

None Food Assistance (Food Stamps, Bridge Card, SNAP) Medicaid Public Housing Temporary Assistance to Needy Families (TANF) Supplemental Security Income (SSI) VA / Veteran's Benefits Other
Assets
Do you have cash on hand or money in savings or checking accounts? *

Yes No
Total $ Amount for Cash/Savings/Checking *
Do you own any vehicles such as auto, recreational or watercraft? *

Yes No
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? *

Yes No

Total 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 the Court to appoint counsel to me. 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 a Court 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