Title: AFFIDAVIT OF INDIGENCY
Author: ttuttle
Last saved by: Joel Lieurance
Company: Microsoft

_APPLICATION _FOR _COURT-APPOINTED _ATTORNEY
_(JUVENILE)
_This _section _to _be _filled _out _by _Court _Personnel

_CAUSE _#  	

The State of Texas	In the vs.
 Court

_Brazoria _County, _Texas

JP #: Bond:

Offense:  
_Level _of _Offense:

All information must be completed by the parent(s)/guardian(s) and must be current, accurate, and true. Intentionally or knowingly giving false information may result in your prosecution for the offense of aggravated perjury, a felony.  The punishment for aggravated perjury includes imprisonment not to exceed ten (10) years and a fine not to exceed ten thousand dollars ($10,000).  Please fill in all blanks.  If you do not know the information being asked, enter DO NOT KNOW in the blank.  If the information being asked does not apply to you, enter N/A in the blank.

FATHER/STEP-FATHER’S PERSONAL INFORMATION
Name:
Phone:                                                     Alt. No. or Contact:
Address:                                                                 Apt. No.
City/State/Zip:
SSN:                                            DL/ID:                                                DOB:
Spouse:                                                                        No. of dependents living with you:
List dependents below: | Age | Relation | Income
Employer:                                                                   Phone No.
Address:
Pay Rate: ______________         Hours worked weekly:
If UNEMPLOYED, list the last job you had: ____________________________________________  ow long your’ve been unemployedand the efforts you’ve made to gain employment:

and length of time unemployed: ______________.  What efforts have you made to gain 
 
\

employment?: ____________________________________________________________________
Spouse’s Employer:                                                              Phone No.
Address:
Pay Rate:                  Hours worked weekly:

Public Assistance: (check all that apply)
Are you currently receiving (check all that apply)

____ Food Stamps $______
    ____ Medicaid
    ____ Public Housing
    ____ Temporary Assistance to Needy Families (TANF) $______
    ____ Supplemental Security Income (SSI) $______

FATHER AND STEP-PARENT FINANCIAL INFORMATION:  
					
MONTHLY EXPENSES: | PAYMENTS: | | MONTHLY INCOME: | AMOUNT:
RENT/MORTGAGE | | | TAKE HOME PAY |
CAR PAYMENT | | | SPOUSE’S TAKE HOME PAY |
INSURANCE (Life, Health, Auto, Homeowners, Renters, ETC.) | | | SIDE JOB/ODD JOBS |
CHILD CARE | | | UNEMPLOYMENT |
CHILD SUPPORT | | | WORKMAN’S COMP. |
WATER | | | PENSION PAYMENTS |
GAS/PROPANE | | | VA BENEFITS |
ELECTRICITY | | | SOCIAL SECURITY BENEFITS (Retirement, Disability, Survivors) |
FOOD | | | CHILD SUPPORT |
MEDICAL | | | ALIMONY |
CABLE TV/SATELLITE TV | | | RENTAL INCOME |
CELL PHONES | | | INVESTMENT INCOME |
LOANS | | | ROYALTIES, CAPITAL GAINS |
CREDIT CARDS | | | ESTATES, TRUSTS |
AUTO FUEL | | | STOCKS/BONDS DIVIDENDS |
OTHER (Describe) | | | OTHER (Describe) |
TOTAL MONTHLY EXPENSES: | $ | | TOTAL MONTHLY INCOME: | $

ASSETS | | | Value

Place of Residence _____ Rent  _____ Own _____ Buying
person on lease/deed:

$

Real Property Owned -Description/Location: | $ |

Automobile
       Year:                     Make:                         Model:

$

Automobile
       Year:                      Make:                        Model:

$

Stocks and Bonds | | $ |
Other Property (list: jewelry, tools, equipment, watercrafts, etc.) | $ |

Name of Bank:

Type of Account:
Balance:

$

Name of Bank:

Type of Account:
Balance:

$

ASSETS TOTAL VALUE | | $

I have / have not (circle one) attempted to hire an attorney.  The names of the attorneys I have contacted are as follows: _________________________________________________________________________

MOTHER/STEP-MOTHER’S PERSONAL INFORMATION
Name:
Phone:                                                     Alt. No. or Contact:
Address:                                                                 Apt. No.
City/State/Zip:
SSN:                                            DL/ID:                                                DOB:
Spouse:                                                                        No. of dependents living with you:
List dependents below: | Age | Relation | Income
Employer:                                                                   Phone No.
Address:
Pay Rate: ______________         Hours worked weekly:
If UNEMPLOYED, list the last job you had: ____________________________________________  ow long your’ve been unemployedand the efforts you’ve made to gain employment:

and length of time unemployed: ______________.  What efforts have you made to gain 
 
\

employment?: ____________________________________________________________________
Spouse’s Employer:                                                              Phone No.
Address:
Pay Rate:                  Hours worked weekly:

Public Assistance: (check all that apply)
Are you currently receiving (check all that apply)

____ Food Stamps $______
    ____ Medicaid
    ____ Public Housing
    ____ Temporary Assistance to Needy Families (TANF) $______
    ____ Supplemental Security Income (SSI) $______

CONTINUED ON NEXT PAGE

MOTHER AND STEP-PARENT FINANCIAL INFORMATION: 	
MONTHLY EXPENSES: | PAYMENTS: | | MONTHLY INCOME: | AMOUNT:
RENT/MORTGAGE | | | TAKE HOME PAY |
CAR PAYMENT | | | SPOUSE’S TAKE HOME PAY |
INSURANCE (Life, Health, Auto, Homeowners, Renters, ETC.) | | | SIDE JOB/ODD JOBS |
CHILD CARE | | | UNEMPLOYMENT |
CHILD SUPPORT | | | WORKMAN’S COMP. |
WATER | | | PENSION PAYMENTS |
GAS/PROPANE | | | VA BENEFITS |
ELECTRICITY | | | SOCIAL SECURITY BENEFITS (Retirement, Disability, Survivors) |
FOOD | | | CHILD SUPPORT |
MEDICAL | | | ALIMONY |
CABLE TV/SATELLITE TV | | | RENTAL INCOME |
CELL PHONES | | | INVESTMENT INCOME |
LOANS | | | ROYALTIES, CAPITAL GAINS |
CREDIT CARDS | | | ESTATES, TRUSTS |
AUTO FUEL | | | STOCKS/BONDS DIVIDENDS |
OTHER (Describe) | | | OTHER (Describe) |
TOTAL MONTHLY EXPENSES: | $ | | TOTAL MONTHLY INCOME: | $

ASSETS | | | Value

Place of Residence _____ Rent  _____ Own _____ Buying
person on lease/deed:

$

Real Property Owned -Description/Location: | $ |

Automobile
       Year:                     Make:                         Model:

$

Automobile
       Year:                      Make:                        Model:

$

Stocks and Bonds | | $ |
Other Property (list: jewelry, tools, equipment, watercrafts, etc.) | $ |

Name of Bank:

Type of Account:
Balance:

$

Name of Bank:

Type of Account:
Balance:

$

ASSETS TOTAL VALUE | | $

I have / have not (circle one) attempted to hire an attorney.  The names of the attorneys I have contacted are as follows: _________________________________________________________________________

On this day ____ of _________, 20_____, I have been advised of my right to representation by counsel to defend my child as to the charge(s) pending against my child.  I am without means to employ counsel of my own choosing and I hereby request the court to appoint counsel for my child. By signing my name below, I swear that all of the above information about my financial condition is current, accurate, and true.  I understand that a court official can verify any of the information for accuracy.  I understand that if my child receives an appointed attorney, it is important that we: (1) keep all appointments with the attorney; (2) attend all court settings on time; and (3) notify the attorney or the attorney’s office of any changes in residence, telephone numbers, or employment within twenty-four (24) hours of such change.

I understand that if I am found to be partially indigent, I am hereby ordered to pay an amount not to exceed the actual costs, including any expenses and costs, paid by Brazoria County for the legal services provided by an appointed attorney during the pendency of the charges.  If found to be partially indigent, prior to the appointment of counsel, I shall pay $100 if charged with one or more misdemeanors or $250 if charged with one or more felonies, pursuant to the Brazoria County Standards and Procedures Related to Appointment of Counsel for Indigent Juveniles, which shall be credited toward the actual costs owed by me, the Parent(s)/Guardian(s), for legal services.

_Applicant’s _Signature 

                                          
     SUBSCRIBED and SWORN to before me, the undersigned authority, this _____ day of
      _____________________, 20_____.

						_________________________________________
						BY:  NOTARY/OFFICER

RECOMMENDATION:
£  Indigent
£  Partially Indigent
£  Does Not Qualify            Verified on                          by                                                          

After reviewing this application for court appointed attorney, I find that this parent/guardian is indigent / partially indigent (circle one) under the guidelines of Brazoria County and is entitled to appointment of an attorney; therefore, the Court appoints _________________________ as the juvenile’s attorney.

Date	Judge/Court Designee

Application for Court Appointed Attorney (Juvenile) 2020 		Page  of 5