Fill and Sign the Application for Appointment of a Court Interpreter in a Civil or Form

In the Iowa District Court for County State of Iowa or Plaintiff/Petitioner, vs. Defendant/Respondent No. Financial Affidavit and Application for Appointment of Counsel In support of my application for appointment of counsel, and under penalty of perjury, the undersigned states: Name: Date of birth: Home phone: Street address: Cell phone: Email: Street/P.O. . Box Apt # City State Zip Pending charges: . In jail? Yes No Do you have a job? No job Yes, full time Yes, part time (list hours per week: Who do you work for? How much money do you currently make, before taxes or deductions? per hour month year How much money have you made in the last 12 months from any source, before taxes or deductions? How many family members are supported by or live with you? If a spouse lives with you, how much money does your spouse make? per hour month year List all other money you, and anyone else living in your household, has coming in: List what you own, including money in banks, cars, trucks, other vehicles, land, houses, buildings, cash, or anything else worth more than $100: List amounts you pay monthly for mortgages, rent, car loans, credit cards, child support, and any other debts: I understand I may be required to repay the state for all or part of my attorney fees and costs, I may be required to sign a wage assignment, and I must report any changes in the information submitted on this financial affidavit. I promise under penalty of perjury that the statements I make in this application are true, and that I am unable to pay for an attorney to represent me. Date Signature Rule 1.1901 — Form 8:Financial Af�davit and Application for Appointment of Counsel