APPLICATION AND ORDER FOR COURT APPOINTED ATTORNEY Date: ____________________________________________________ Defendant: _______________________________________________ Time: __________________________________________________ Charge: ________________________________________________
APPLICATION FOR COURT APPOINTED ATTORNEY
Every question on this form must be answered. Failure to do so could result in the application not being considered. If you need assistance, notify the person in charge of taking this application. You must answer each question truthfully, failure to do so could subject you to additional criminal charges.
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Last Name ____________________________________ First Name ______________________________________ Middle _______________ Address ____________________________________________________________________________________________________________ Number and Street City State Phone Married ____ Single ____ Divorced ____ Separated ____ Social Security No. __________________________ Date of Birth _____________ Name of Spouse ______________________________________________________________________________________________________ Number of children under 18 living with you ___________ Ages _______________________________________________________________ Are you paying? __________ Receiving? ______________ child support? How much? _____________________________________ Per Mo. Do you receive any public assistance? __________ If yes, amount $_____________________ Agency _________________________________ Are you employed? _________________________ If yes, name of employer _____________________________________________________ Your wages $__________________ Per________________ Spouse income, if available $_______________ Per ________________________
10. Are you receiving income or benefits from any other source? Yes ______ No ______ If yes, from whom received, frequency of payment, and date payments end. __________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ 11. Names of employers for the last two years and monthly salary for each. __________________________________________________________ ___________________________________________________________________________________________________________________ 12. Closest relative ________________________________________________________Phone__________________________________________ MONTHLY EXPENSES/PAYMENTS Rent/House payment Car Payment Credit Cards Loan Payments Medical Payments Child Care Child Support Insurance Utilities Food & Clothing IRS/Other TOTAL INCOME DIFFERENCE TOTAL OF DEBTS OWED House Loan Car Loan Credit Cards Loans Medical Taxes IRS Other TOTAL House Value Car Value Cash Bank Accounts Stocks Jewelry Furniture Other TOTAL ASSETS
Cause No. ________________ THE STATE OF TEXAS VS. ______________________________ § § § § § IN THE COUNTY COURT AT AT LAW No. __________ TOM GREEN COUNTY, TEXAS
REQUEST AND ORDER FOR APPOINTMENT OF COUNSEL "My name is __________________________________________. I am the defendant in this case. Today the judge presiding advised me of my right to be represented by a lawyer, either one that I hire, or if I am indigent or the interests of justice require, a lawyer appointed by the judge as well as the procedure for making this request. I understand I have the right to represent myself. I believe that I am indigent and I am requesting the Court appoint counsel to represent me. I understand that if there is a material change in my financial circumstances after a determination of my indigence is made, that I, my counsel, or the county attorney representing the State may ask the judge to reconsider the judge’s decision. In support of this request I have provided the judge with personal and financial information and I am giving sworn testimony before the judge about my personal and financial circumstances. I understand this information may not be used for any purpose except to determine my indigency or to impeach any future testimony I may give in this case. I understand that I may be subject to prosecution for the felony offense of aggravated perjury in the event I intentionally or knowingly give false testimony to the Court in this matter." I received assistance in completing this request from ______________________________________________________, a court services officer, court clerk, other __________________________. _______________________________________ Defendant
SWORN to and subscribed before me, the undersigned authority, on _____________________________________, 20 _______. By:_____________________________________________________ ________________________________________________________ Title of Official taking Oath (Notary, County Clerk, etc.)
ORDER DETERMINING RIGHT TO APPOINTMENT OF COUNSEL Today the defendant’s request for the appointment of counsel was heard in open court and evidence presented concerning the defendant's financial resources. INDIGENCY WITH REIMBURSEMENT. The Court finds the defendant is entitled to the appointment of counsel because defendant is indigent it is in the interests of justice. The Court further finds Defendant presently has financial resources to pay all or part of the cost of legal services and related expenses. IT IS HEREBY ORDERED that Defendant is appointed counsel and shall contribute to the cost of legal services and related expenses as may be ordered by the Court. INDIGENCY WITHOUT REIMBURSEMENT. The Court finds the defendant is entitled to the appointment of counsel because defendant is indigent it is in the interests of justice. The court further finds Defendant presently has no financial resources to offset the cost of legal services and related expenses. IT IS HEREBY ORDERED that defendant is appointed counsel in this matter. The Court appoints the attorney named below to represent the defendant until charges are dismissed, the defendant is acquitted, appeals are exhausted, or the attorney is relieved of his duties by the court or replaced by other counsel. Attorney _____________________________________________________________________________________________
NO FINANCIAL NEED. The defendant has the financial resources to employ counsel and the appointment of counsel in the
interests of justice is not necessary. The request is DENIED at this time.
Signed ___________________
__________________________________________ MAGISTRATE/PRESIDING JUDGE