Fill and Sign the Court Appointed 497323988 Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE JUVENILE COURT OF THE STATE OF OREGON FOR THE COUNTY OF _____________ PLEASE PRINT LEGIBLY IN THE MATTER OF ) Legal # _ __________________________ ) Charges ) _____________________________________ , ) Child ) Approve Deny ____ STATE OF OREGON ) AFFIDAVIT OF INDIGENCY / REQUEST FOR COURT APPOINTED ATTORNEY / ) AGREEMENT TO REPAY County of _ _____ ) I, the undersigned, being duly sworn, say I am the parent/guardian of the youth in the above case. I am asking for appointment of an attorney to represent ____________________ in this case because I cannot pay for an attorney now without causing substantial hardship to myself or my family. The following information is true and I ask the Court to use the information to decide whether I can have an attorney and payment of other costs at public expense. I understand that if I don’t tell the truth, I may be charged with perjury or false swearing and, if convicted, I may be imprisoned. I am providing my social security number on a voluntary basis. I understand that I cannot be compelled to provide it or be denied consideration solely for failing to provide it. Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 It may be used to verify my identification, credit and employment information, used for collections purposes, or for any court-imposed monetary obligation. I. BASIC FACTS AND HOUSEHOLD INFORMATION: (Parent/Guardian) Full Name _________________________________ Date of Birth _______________________ Address ___________________________________ Telephone _________________________ Mailing Address _____________________________ SSN ______________________________ Sex ____ Single ____ Married ____ Separated ____ Divorced ____ Divorce Filed _____ Renting _____ Buying _____ Mobile Home ______ If buying, estimated value $_________ Amount Owed $________ Owner Name _____________ Who else lives there? (Include children, spouse, other family members, roommates. List name, date of birth, relationship and gross/net monthly income of each):  None ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Children living outside your home for whom you must pay Court ordered child support:  None ______________________________________________________________________________ ____________________________________________________________________________ II. INCOME: Are you employed? Yes ___ No ___ If not, how are you supported? _______________________ List your employment for the last 2 years: Employer Address Dates Employed Monthly Income – NET ______________________________________________________________________________ ____________________________________________________________________________ List spouse’s employment for the last 2 years:  None Source Monthly Income - NET _____________________________________________________________________________ List all sources of income for your family such as retirement, alimony, child support, public assistance, worker’s compensation, disability, food stamps, social security, etc .: Source:____________________________________ Monthly Amount: $___________________ Source:____________________________________ Monthly Amount: $___________________  None Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 III. REAL ESTATE : Description: Balance Owed Equity _____________________________________________________________________________ AUTOMOBILES & OTHER MOTOR VEHICLES , owned by you and your spouse:  None Make & Year What it is worth Amount Owed ______________________________________________________________________________ ____________________________________________________________________________ BANK ACCOUNTS OR CASH , owned by you and your spouse:  None Bank/Branch Balance Cash ______________________________________________________________________________ ____________________________________________________________________________ ALL OTHER PROPERTY OR ASSETS , (stocks, bonds, guns, boats, jewelry):  None Item What it is worth Amount Owed ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IV. DEBTS :  None Creditor Amount Owed Monthly Payment Last Paid ______________________________________________________________________________ ____________________________________________________________________________ MONTHLY EXPENSES :  None Whom Amount Owed Monthly Payment ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ If I get a Court Appointed Attorney, I agree to pay the Court back for reasonable attorney fees and costs paid in my defense, as ordered by the Court. I understand that the information on this form may be given to the District Attorney’s Office . Date ________________________ _____________________________________________ (Parent/Legal Guardian) Subscribed and Sworn to before me this ______ day of ___________,_______. _____________________________________________ Clerk / Notary / Judge My commission expires: _________________________ Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ____________________________ is hereby appointed to represent ____________________ Dated this _________ day of _________________, _________. ________________________________ Circuit Court Judge Pro Tem Affidavit of Indigency; Request for Court Appointed Attorney; Agreement to Repay 6