Fill and Sign the Petition Counsel Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use       -vs- Petition for Appointment of Counsel, Affidavit of Indigency and Order       Case No.       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 for 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 would 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 court 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 :       Original: Clerk of Court/Register in Probate BY THE COURT: Circuit Court Judge       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. Petition for Appointment of Counsel, Affidavit of Indigency and Order Page 2 of 2 Case No. Error: Reference source not found Section 2. Complete this section only if you do not qualify under Section 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 expenses, other than ordinary living expenses:       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