FINANCIAL AFFIDAVIT
For Court-Appointed Attorney, Expert or Other Services (K.A.R. 105-4-3) Judicial Dist. County CASE NO. FALSE STATEMENTS COULD RESULT IN ANOTHER CASE BEING FILED AGAINST YOU!! Birth Year
FOR CLERK'S USE ONLY
Name Address
Age City
Phone State
S.S.# xxx-xxZip Code
Spouse (If married including common-law) 1. Are you Self-Employed Employed Unemployed
If self-employed, what line of work? If employed, who do you work for? If unemployed, for how long? Are you receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 2. List the places you have worked in the last six months: 1. 2. 3. 3. 4. Name Name Name Address Address Address
If employed, give an approximate monthly rate of pay Is your spouse Self-Employed Employed Unemployed
If self-employed, what line of work? If employed, who does he/she work for? If employed, give an approximate monthly rate of pay If unemployed, for how long? Is he/she receiving unemployment benefits? Amount $___________ If, not, state reason _____________________________ 5. Do you own a car, truck, or motorcycle? If yes, give year, make and model: 1. 2. Please give value 6. Is it paid for? Yes No Amount owing Yes No
Do you receive, or have you received, in the past six months, income from rental property, public assistance, support, alimony, maintenance, or other sources, including from a business? If yes, give source and monthly income: Yes No
7.
Do you have money or cash in savings, checking accounts or other funds? If yes, list amount of money available to you
Yes
No
8. 9.
Do you own a home, land, or other property?
Yes
No If yes, give value Yes No
Can you afford to pay anything toward the costs of your defense at this time? If yes, how much
10.
Do you currently have any other court cases pending in the District, in which you already have counsel appointed? Yes No
If yes, give attorney's name
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(Check One) SINGLE MARRIED WIDOWED SEPARATED/DIVORCED
DEPENDANTS TOTAL NUMBER LIST NAMES, AGES AND RELATIONSHIP TO YOU
MONTHLY BILLS RENT/HOUSE PAYMENT FOOD/CLOTHING UTILITIES ALIMONY/MAINTENANCE CHILD SUPPORT INSTALLMENT PAYMENTS OTHER PAYMENTS TOTAL PAYMENTS
I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorize the STATE OF KANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings, and any other asset balances that are needed to process this affidavit with the district court. I further authorize the STATE OF KANSAS to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references. Executed this day of , 20 .
____________________________________________________
Signature of Applicant FOR JUDGE'S USE ONLY
DETERMINATION OF ELIGIBILITY K.A.R. 105-4-1(b): "An eligible indigent defendant is a person whose combined household income and liquid assets equal less than the sum of the defendant's reasonable and necessary living expenses plus the anticipated cost of private legal representation."
TO BE COLLECTED PURSUANT TO K.S.A. 22-4529: APPLICATION FEE OF $100 effective 7/1/04
Estimate of anticipated cost of private legal representation: APPOINTMENT DENIED PARTIALLY INDIGENT, ABLE TO PAY $ PUBLIC DEFENDER APPOINTED ATTORNEY APPOINTED
Applicable poverty guideline level:
Judge
2007 Poverty Guidelines for the 48 Contiguous States & the District of Columbia
Size of Family Unit Poverty Guideline
1......................................................$ 10,210 2......................................................$ 13,690 3......................................................$ 17,170 4......................................................$ 20,650 5......................................................$ 24,130 For family units with more than 5 members, add $3,480 for each additional member.
Revised 06/08/07
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