Fill and Sign the 7a 450 Et Seq Form

Employment - A pplican t $ $ Total Monthly Income $ STATE OF NORTH CAROLINA F ile No. $ Car Ex penses (gas, insurance, etc.) S he lter Ot he r:(specify) F oo d (including Food Stamps) Utilities (power, water, heating, phone, cable, etc.) H ea lth Care Installm ent Paym ents S uppo rt Paym ents $ $ Total Monthly Expen ses (Fair Market Value) (Fair Market Value) $ $ $ (Fair Market Value) (Balance Due) Total A ssets And Liabilities Mone y Ow ed To Or Held For A pplican t (Over) Num ber Of D ependen ts Pers onal Prope rty R ea l Estate Motor V ehicles (List Make, Model, Year) Cash On H and And In B ank Acc ounts (List Name Of Bank & Account No.) DESCRIPTION OF ASSETS AND LIABILITIES (Balance Due)(Balance Due) ASSETS (t hi ng s y ou own) LIABILITIES (am oun ts you owe) $ $ $ $ Vehicle Other $ $ Name And Address Of Applicant's Employer (If not employed, state reason; if self-employed, state trade) Other Income (Welfare, Food Stamps, S/S, Pen sions, etc.) Employment - Spouse Buying Renting Name And Address Of Spouse's Employer $ $ $ $ $ $ $ MONTHLY EXPENSES (mon ey y ou pay out) App lica nt: Do y ou ha ve ot her pend ing crimi nal cha rge (s) in which a lawyer has been appo inted ? Yes No La st Income Tax Fil ed 20 Ot he r D ebts Ot he r Bond Type AOC- CR-226, Rev. 10/13 © 2013 Administrative Office of the Courts By Whom Posted $ $ $ Fu ll Social Security No. Of Applicant Has No Social Security No. - - Name Of Lawyer MONTHLY I NCOME (mon ey y ou make) Refund Owe $ $ Amount NOTE: Read the no tice on the reverse si de be fore completi ng this form. (TYPE OR PRINT IN BL ACK INK ) Coun ty Name Of App licant AFFI DAVIT OF I NDIGENC Y G.S. 7A-450 et seq. Additional F ile Nos. In T he Gene ral Cou rt Of Justice Di strict S uperio r Cou rt Di vis ion Street Number And Street Name, Including Apartment Or Unit Number If Applicable Fu ll Permanent Ma iling Address Of App licant (If Different Than Above) $ $ Offense(s) DefendantParent/Guardian/Trustee Date Of Birth Telephone Number Of App licant City, State And Zip Code County Where Notarized Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate If y ou are less t han 18 years old, or if you are at least 18 years old but remain dependent on and live with a parent or gu ardian, state name and ad dress of parent, guardian or trustee below. NOTE: Name Of Parent/Guardian Or Trustee Address City, State, Zip Notary SEAL SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Defendant Parent/Guardian/Trustee The information you prov ide may be verif ied, and your s ignature be low wil l serve as a r elease permitt ing the interv iewer to contact your cr editors, em ployers , family members, and others concer ning your eligibility for a court-app ointed lawyer. A false or dis honest answer concer ning your f inancial status c ould lea d to prosecut ion for perjury. See G.S. 7A- 456(a) ("A false mater ial statement m ade by a person under oath or affirmat ion in r egard to the quest ion of his indi ge ncy constitutes a Class I f elo ny."). 3. Signature Signature Of ApplicantDate Name Of Applicant (Type Or Print) Date My Commission Expires Governmental Agencies Or Other Entities Authorized To Be Contacted And/Or To Release Information Und er pe nalty of perjury , I declare tha t the informat ion prov ided on this form i s true and corre ct to the best of my k now ledg e, and tha t I am f inancially una ble to em ploy a lawyer to represent me. I no w r equ est the Court to ass ign a la wyer to represent me in this case. I authorize the Court to contact my cr editors, em ployers, or family members, any governmental agencies or any other entities listed be low concer ning my eligibility for a court-app ointed lawyer. AOC-CR-226, Side Two, Rev. 10/13 © 2013 Administrative O ffice of the Courts N OT ICE TO PERSONS REQUESTING A COURT-APPOINTED LAWYER W he n answer ing the quest ions on the Aff idavit Of Indi gency (reverse side of this form) , ple ase do not discuss your case with the interv iewer. The interv iewer can be calle d as a witness to testify about any statements m ade in his/her presence . P lease wait an d s peak with your lawyer. Do not ask the interv iewer for any advice or opinion concer ning your case. 1. A court-appointed lawyer is not free. If you ar e convicte d or plead g uilty or no contest, you may be re quired to repay the cost of your lawyer as a part of your s entence. The Court may also enter a civ il j ud gment against y ou, whic h wi ll acc rue int ere st at the legal rate set out in G.S. 24-1 from the date of the entry of j udgment. Your North Caroli na Tax Ref und may be t aken t o pay for the cost of your court-app ointe d lawyer. In add itio n, if you are convicte d or plead guilty or no contest, the Court must charge y ou an attorney app ointment fee and may enter this fee as a civ il jud gment against you pursuant to G.S. 7A- 45 5.1. 2. I further authorize my cr editors, em ployers, or family members, any governmental agencies or any other entities listed be low to r elease f inancial informat ion concerning my eligibility for a court-app ointed lawyer upon requ est o f the Court.