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Financial Affidavit

To be an eligible affiant of this affidavit, individual must be a Defendant who cannot afford to pay for attorney fees. By executing this affidavit, Defendant is declaring her/his desire to avail of the court’s free legal counsel and other defense services.Download

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APPLICATION FOR APPOINTED DEFENSE SERVICES(To accompany Financial Affidavit)STATE VS. _______________________________ DISTRICT COURT CASE NO. _____________      OrIN RE:____________________________________ COUNTY _____________________________NOTICE TO APPLICANT:ANY DEFENDANT CHARGED WITH A FELONY VIOLATION,  ENTITLED TO AN ATTORNEY PURSUANT TOK.S.A. 22-4503, IS REQUIRED BY LAW TO PAY A $100 BOARD OF INDIGENTS DEFENSE SERVICES APPLICATIONFEE, UNLESS THE FEE IS WAIVED BY THE COURT.  THE FEE IS TO BE PAID TO THE CLERK OF THE DISTRICTCOURT.  FAILURE TO PAY THIS FEE MAY BE CONSIDERED A VIOLATION OF THE CONDITIONS OF YOURRELEASE AND YOUR BOND MAY BE REVOKED FOR FAILURE TO PAY SAID APPLICATION FEE.A.GENERAL INFORMATION1.  The information on the attached affidavit is not confidential.2.  Any information contained on the attached affidavit may be verified by the judge or the      Kansas Board of Indigents= Defense Services.3.  False entries may lead to criminal prosecution and conviction.4.  If you do not understand a specific question or need help, ask for assistance.5.  The judge may place you under oath and inquire further about any information provided     on this form.B.ELIGIBILITY FOR DEFENSE SERVICES1.  Appointed counsel and other defense services will only by provided to people who cannot     afford to pay for these services themselves.2.  If the judge determines that you are able to pay a part of the costs of your defense, you will     be found partially indigent and the court will order you to pay for a part of these costs.3.  If, after the date of the alleged offense, you transfer any of your property for less than it is                  worth, the State may sue to obtain repayment of the cost of your defense.4.  You must inform the court if there is a change in any of the financial information given on the     affidavit.C. REPAYMENT TO THE STATEK.S.A. 1997 Supp. 21-4603 provides that persons who are convicted of a crime must reimburse the state general fundfor all or part of the attorney fees and expenses paid by the Kansas State Board of Indigents= Defense Services.  K.S.A. 1997Supp. 21-4610 also provides that persons who are placed on probation or whose sentence is suspended must, as a condition ofprobation, reimburse the state general fund for all or part of the attorney fees and expenses paid by the Kansas State Board ofIndigents= Defense Services.The court shall take into account the financial resources and the nature of the burden that payment of such sum will impose. Any person who has been required to pay such sum and who is not willfully in default may petition the sentencing court to waivepayment of any remaining balance or portion thereof.I have read or have had read to me and understand the above notice.  I hereby request that court-appointed counsel beprovided tome and agree to attempt to repay the State for the costs of my defense if the court so orders.__________________________________________________________________                DateSignature of Defendant

FINANCIAL AFFIDAVITFor 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.Name ______________________________ Age____ D.O.B. _________Phone ____________ S.S.#___________Address ____________________________ City ___________________ State _____________ Zip Code _______Spouse (If married-including common-law)__________________________________________________________1.Are you          ” Self-Employed” Employed” UnemployedIf self-employed, what line of work? _____________________________________________________If employed, who do you work for? ______________________________________________________If unemployed, for how long? __________________________________________________________2. List the places you have worked in the last six months:1.  Name ______________________________   Address _____________________________________2.  Name ______________________________   Address _____________________________________3.  Name ______________________________   Address _____________________________________3. If employed, give an approximate monthly rate of pay ________________________________________4.Is your spouse          ” Self-Employed” Employed” UnemployedIf 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? ___________________________________________________________5.Do you own a car, truck or motorcycle?  ” Yes” NoIf yes, give year, make and model: ________________________________________________________Please give value _______________ Is it paid for?  ” Yes  ” No   Amount owing _________________6.Do you receive, or have you received, in the past six month, income from rental property, public assistance,              support, or other sources, including from a business?   ” Yes   ” NoIf yes, give source and monthly income: ___________________________________________________7.Do you have any money or cash in savings, checking accounts or other funds?   ” Yes   ” NoIf yes, list amount of money available to you _______________________________________________8.Do you own a home, land or other property?   ” Yes    ” No    If yes, give value _________________9.Can you afford to pay anything toward the costs of your defense at this time?   ” Yes    ” NoIf yes, how much _____________________________________________________________________

Determination of Eligibility - K.A.R. 105-4-1(b): AAn eligibleindigent defendant is a person whose combined household incomeand liquid assets equal less than the sum of the defendant=sreasonable and necessary living expenses plus the anticipated cost ofprivate legal representation.@10.Do you currently have any other court cases pending in the District, in which you already have counselappointed?   ” Yes    ” NoIf yes, give attorney=s name __________________________________________________(Check One)” SINGLE” MARRIED” WIDOWED” SEPARATED/    DIVORCED       DEPENDENTSTOTAL NUMBER ______________LIST NAME, AGES ANDRELATIONSHIP TO YOU________________________________________________________________________________________________________________________MONTHLY BILLSRENT/HOUSE PAYMENT _________FOOD/CLOTHING _______________UTILITIES _____________________ALIMONY _____________________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 authorized the STATE OFKANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings and any other assetbalances that are needed to process this affidavit with the district court.  Further authorize the STATE OF KANSAS toorder a consumer credit report and verify other credit information, including past and present mortgage and landlordreferences.Executed this _________ day of ________________________, ________.__________________________________________Signature__________________________________________________________________________________FOR JUDGE=S USE ONLY”APPOINTMENT DENIED”PUBLIC DEFENDER APPOINTED”ATTORNEY APPOINTED”APPLICATION FEE OF $100 TO BE COLLECTED IMMEDIATELY AS A CONDITION OF RELEASE(K.S.A. 22-4529, 2003 H.B. 2121 effective May 1, 2003)”PARTIALLY INDIGENT, ABLE TO PAY $_____________________________________________________JUDGE2002 Poverty Guidelines for 48 Contiguous States & the Guidelines for estimated copy of private legal reprensationDistrict of ColumbiaSize of Family UnitPoverty GuidelineSecurity levelNondrug CostDrug Cost

1     $ 8,860Off-Grid$6,0002     $11,940     1$7,158$3,060 3     $15,020     2$5,168$4,3344     $18,100     3$4,542$3,3685     $21,180     5$2,340$2,324For family units with more than 5 members, add     6$2,964$3,080 for each additional member     7$4,330     8$2,524     9$1,754   10$2,640
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