Comes the defendant and, subject to the penalty of perjury, makes oath to the following facts (please list, circle, complete, etc.):

PART I
1. Full Name: _________________________________   	2. Social Security No.: _________________ 

3. Any other names ever used: ____________________   	4.  Address: _________________________ 

5. Telephone Nos.: (Home) __________________ (Work) _________________ (Other) __________________ 

6. Are you working anywhere? Yes (  ) No (  ) Where ______________________________________________ 

7. How much do you make? __________ (weekly, monthly, etc.) 	8. Birth date: _________________________ 

9. Do you receive any governmental assistance or pensions (disability, SSI, AFDC, etc.)?  Yes ( ) No ( ) 
	What is its value? ________________________ (weekly, monthly, etc.)

10. Do you own any property (house, car, bank acct., etc.): Yes ( ) No ( ) 
	What is its value? ______________________________________________________ 

11. Are you, or your family, going to be able to post your bond? Yes ( ) No ( )

12. Are you, or your family, going to hire a private attorney? Yes ( ) No ( )

13. Are you now in custody? Yes ( ) No ( ) 
	If so, how long have you been in custody? ____________________________________________________ 
(If the defendant is in custody, unable to make bond and the answers to questions one (1) through eleven (11) make it clear that the defendant has no resources to hire a private attorney, skip Part II and complete Part III. If Part II is to be completed, do not list items already listed in Part I.)

PART II
14. Names & ages of all dependents: ________________________ 	relationship ____________________
	___________________________________________________ 	relationship ____________________ 
      ___________________________________________________	relationship ____________________

15. I have met with following lawyer(s), have attempted to hire said lawyer(s) to represent me, and have been unable to do so: 
Name ____________________________________ 	___________________________________ 
Address ___________________________________	___________________________________

16. All my income from all sources (including, but not limited to wages, interest, gifts, AFDC, SSI, social security, retirement, disability, pension, unemployment, alimony, worker's compensation, etc.):

  $ ______________ per ________________________ from ____________________________________________________ 

  $ ______________ per ________________________ from ____________________________________________________ 

  $ ______________ per ________________________ from ____________________________________________________ 

17. All money available to me from any source:  
	A. Cash __________________ 
	B. Checking, Saving, or CD Account(s)-give bank, acct. no., balance __________________________________________ 
	C. Debts owed me __________________________________________________________________________________
	D. Credit Card(s)-give acct. no., balance, credit limit, and type (Visa, Mastercard, American Express, etc.) ____________
		_________________________________________________________________________________________________
	E. Other ___________________________________________________________________________________________

18. All vehicles/vessels owned by me, solely or jointly, within the last six months (including but not limited to cars, trucks, motorcycles, farm equip., boats etc.):

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

19. All real estate owned by me, solely or jointly, within the last six months (including land, lots, houses, mobile homes, etc.):

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

20. All assets or property not already listed owned within the last six months or expected in the future:

  _____________________________ value $ __________________ amt. owed _________________

  _____________________________ value $ __________________ amt. owed _________________ 

21. The last income tax return I filed was for the year ______ and it reflected a net income of $ ___________________________. 
I will file a copy of same within one week if required.

22. I am out of jail on bond of $ ___________ made by ___________________________.  The money to make bond, $ ________ was paid by __________________________________________________. 
  
PART III
23. Acknowledging that I am still under oath, I certify that I have listed in Parts I and II all assets in which I hold or expect to hold any legal or equitable interest.

24. I am financially unable to obtain the assistance of a lawyer and request the court to appoint a lawyer for me.

25. I understand that it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months 29 days or be fined up to $2500.00 or both if I intentionally or knowingly misrepresent, falsify, or withhold any information required in this affidavit. I also understand that I may be required by the Court to produce other information in support of my request for an attorney.

This __________ day of ______________, ________. 	__________________________________________ 
	Defendant

 Sworn to and Subscribed before me this ____ day of __________, ________.

	__________________________________________
	Clerk

	__________________________________________
	Judge