Fill and Sign the Counsel Affidavit of Form

GF-152, 05/00 Petition for Appointment of Counsel, Affidavit of Indigency and Order US Constitution , Am. 6; Wis. Constitution Art. 1, §7; SCO 93-15; §§48.23, 51.20(3), 814.29, 977.08(3), Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY -vs- Petition for Appointment of Counsel, Affidavit of Indigency and Order Case No. For Official Use Under oath I state that because of poverty, I am unable to pay for an attorney to represent me in this case and request that the court appoint counsel for me. I applied fo r representation through the state public defender but was found ineligible for their services. Complete Section 1 if you receive aid from any of the programs listed. Section 1. If you do not receive aid, complete Section 2 on page 2. I currently receive: Supplemental security income Relief funded under §59. 53(21), Wis. Stats. Medical assistance Food stamps Relief funded under public assistance Benefits for veterans under §45.351(1) or 38 USC 501-562 Legal representation from a civil legal services program or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. If you checked the “has” box, and such changes w ould make you ineligible for the program(s) if you applied today, you must complete Section 2 on page 2 of this form. Subscribed and sworn to before me on Notary Public/Court Official My commission expires: I understand that if my financial situation changes, I must notify the court immediately. Signature Date Address COURT FINDINGS AND ORDER 1. This petition is GRANTED because the cour t finds the person is indigent. Counsel shall be appointed at county expense as set forth below. The person shall be required to reimburse the county for such representation as follows: No reimbursement required. Repayment at the rate of $ per until the total sum is paid. The first payment shall be made on (date) . Payments shall be made to the Clerk of Court. Other: The following attorney is appointed to represent the defendant: Name: Telephone Number: Address: The attorney shall be compensated at: current state public defender rates. $ 2. This petition is DENIED because the court finds: the person is not indigent. Other : BY THE COURT: Circuit Court Judge Original: Clerk of Court/Register in Probate Date GF-152, 05/00 Petition for Appointment of Counsel, Affidavit of Indigency and Order US Constitution , Am. 6; Wis. Constitution Art. 1, §7; SCO 93-15; §§48.23, 51.20(3), 814.29, 977.08(3), Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Petition for Appointment of Counsel, Affidavit of Indigency and Order Page 2 of 2 Case No. Section 2. Complete this section only if you do not qualify under Secti on 1, or if the instructions for that section require you to complete it. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn $ gross weekly. every 2 weeks. twice monthly. monthly. My take-home pay is $ per payperiod. 4. I receive monthly income totaling the amount of $ from: Pension Social security Unemployment compensation Disability Student loans/grants Other: 5. I have the following cash assets: Savings accounts: $ Cash: $ Checking accounts: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Household furnishings: $ Vehicle-Yr./Make: $ Equity in real estate: $ Other individual assets valued over $200 each: $ 7. My household consists of myself and others: Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No 8. The other members of my household have monthly income totaling the amount of $ from: Wages Social security Relief funded under public assistance Food stamps Pension Student loans/grants Unemployment compensation Supplemental security income Disability Relief funded under §59.53 (21), Wisconsin Statutes Support/maintenance Other: 9. I have the following debts; Amount: Monthly Payment: a. Mortgage $ b. Auto loan $ c. Credit cards $ d. Other: $ $ 10. I have the following unusual expense s, other than ordinary living expenses: