Fill and Sign the Cp 410 Request for Appointed Attorney Childrens Proceedings Form

Del.R. 16, CINA R.12 Page 1 of 5 CP-410 (3/16)(cs) REQUEST FOR APPOINTE D ATTORNEY AS 47.10.050, AS 47.12.090 IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of: ) ) ) ) ) ) A minor under 18 years of age. ) CASE NO. ) Date of birth: ) REQUEST FOR APPOINTED ATTORNEY We request that the court appoint an attorney to represent (name) . STATEMENT OF FINANCIAL RESPONSIBILITY We understand that if we are able to pay for some legal services, the court may order us to pay. We also understand that we must pay the State of Alaska for any help given by the Alaska Public Defender Agency or other appointed attorney if it is decided we were not entitled to the assistance. CHILD'S FINANCIAL STATEMENT Fill in this section only if you are requesting an attorney to represent a child. Child's Name Date of Birth Address I. CHILD'S INCOME INFORMATION (after taxes, but before other deductions) a. Income during last 12 months: Wages $ Welfare Child Support Payments Social Security Payments Pension/Trust Fund Payments Other Total Income In the Matter of: Case No. Page 2 of 5 CP -410 (3/16)(cs) Del.R. 16, CINA R.12 REQUEST FOR APPOINTED ATTORNEY AS 47.10.050, AS 47.10.090 II. CHILD'S ASSETS Cash on hand (savings or other accounts) $ Where Land owned Acres and Location Motor Vehicles Number, year, model Securities Stocks, bonds, notes Life Insurance Life Insurance case values/dividends Snowmachines, boats, motors, etc. Collectibles (stamps, coins, antiques) Guns Precious metals/stones Electronic Equipment (computers, TV's, etc.) Permanent Fund Money Received Total Assets PARENTS' FINANCIAL STATEMENT This section must be filled in if you are requesting an attorney to represent either a child or parents. Parent A’s Name Phone # Address Date of Birth Present Employer How Long? (If not employed, give last employer and date terminated.) (If employed less than one year , give previous employer.) Employer Address Employer Phone # * * * * * Parent B’s Name Phone # Address Date of Birth Present Employer How Long? (If not employed, give last employer and date terminated.) (If employed less than one year, give previous employer .) Employer Address Employer Phone # In the Matter of: Case No. Page 3 of 5 CP -410 (3/16)(cs) Del.R. 16, CINA R.12 REQUEST FOR APPOINTED ATTORNEY AS 47.10.050, AS 47.10.090 I. PARENTS' INCOME INFORMATION (after taxes, but before other deductions). a. Income during last 12 months. Parent A Parent B Wages $ Welfare Unemployment Pension or trust Child Support Contributions Social Security Other Total Income b. Current Monthly Income: Parent A’s Income Source: Parent B’s Income Source: II. PARENTS' ASSETS - Present Value Parent A Parent B Cash (checking and savings accounts) $ Land, buildings, mobile homes Acres and Location Motor Vehicles Number, year, model Securities: Stocks, bonds, mutual funds Businesses Snowmachines, boats, motors, etc. Guns Collectibles (stamps, coins, antiques) Jewelry (other than wedding rings) Life Insurance cash value/dividends Pension plans/annuities Permanent Fund Money Received Household goods Electronic equipment (TV's, computers, etc.) Total Assets III. PARENTS' DEBTS Parent A Parent B Mortgages $ Loans Do ctor or hospital bills Charge card bills Total Debts In the Matter of: Case No. Page 4 of 5 CP -410 (3/16)(cs) Del.R. 16, CINA R.12 REQUEST FOR APPOINTED ATTORNEY AS 47.10.050, AS 47.10.090 IV. MONTHLY EXPENSES Food $ Rent Utilities Car payments Furniture & TV payments Child support or alimony Loans/Time payments Total Expenses V. DEPENDENTS: Name Age Relationship * * * * * GENERAL WAIVER We authorize anyone, including our past employers, to give to the Alaska Court System all information about any income source we have had for the past three years since an appointed attorney represented us in our first court appearance. We understand that this information may be given to the Attorney General, if requested after the end of our case. We declare, under oath, that we have read or have had read to us the Statement of Financial Responsibility and the General Waiver. We further declare that this financial statement is true. We understand that if we give false information in the Financial Statement we may be prosecuted for perjury under AS 11.56.200. Date Child's Signature Date Parent A's Signature Date Parent B 's Signature Subscribed and sworn to or affirmed before me at , Alaska, on . (date) (SEAL) Clerk/Notary Public In the Matter of: Case No. Page 5 of 5 CP -410 (3/16)(cs) Del.R. 16, CINA R.12 REQUEST FOR APPOINTED ATTORNEY AS 47.10.050, AS 47.10.090 SUMMARY (To be filled out by court) Child Parent A Parent B Assets Liabilities Available Assets Value For Delinquency matters, what charges have been filed against the child?