FINANCIAL QUESTIONNAIRE AND AFFIDAVIT

Transcription

1 STATE OF INDIANA ) IN THE LAPORTE SUPERIOR COURT NO. 1 ) SS: COUNTY OF LAPORTE ) CAUSE NO.: 46D01- STATE OF INDIANA, ) Plaintiff, ) vs. ) ) ) Defendant ) FINANCIAL QUESTIONNAIRE AND AFFIDAVIT NOTE: THE COURT WILL USE YOUR STATEMENTS ON THIS QUESTIONNAIRE AND THE ANSWERS YOU GIVE TO THE JUDGE TO DETERMINE WHETHER TO PROVIDE A LAWYER FOR YOU AT PUBLIC EXPENSE. You are required to answer every question fully. You will be required to swear under oath or solemnly affirm that you have truthfully answered this Questionnaire. You subject yourself to the penalty for perjury (a Class D felony) if you lie about your financial situation. 1. What is your correct legal name? 2. Where do you live? Street Apartment # City State Zip 3. Who do you live with and whose house is it? 4. Are you married? Yes No. If yes, to whom? Spouse s name 5. Other than your spouse, does anyone depend on you for support? Yes No If yes, state names, ages, and relationship: 1

2 6. State your skill, trade, occupation, or profession:. Are you working? Yes No. If yes, state particulars including name and address of employer(s), monthly take-home pay, job description: If you are not working, state the name and address of your last employer, when employment ended, job you held, and monthly take-home pay: If you are not working, state how you maintain yourself and your dependents (if any): 7. Is your spouse working? Yes No. If yes, state particulars including name and address of employer(s), monthly take-home pay, job description: 8. Do you receive any of the following types of payments? If yes, state monthly amounts: Yes No Interest - total $ Dividends - total $ Pension/Retirement - total $ Public benefits (Social Security, SSI, AFDC, family assistance, etc.) - total $ Rent or royalty - total $ Estate or trust distributions - total $ Purchase payments - total $ Any other type of payment - total $ Explain particulars: 2

3 9. Did you file a federal income tax return for the last calendar year? Yes No. If yes, state the total amount of income you and your spouse reported on that return: $ for the year 200. Do you expect the same amount of income this year? Yes No If not, why not? 10. Do you own, hold, have an ownership interest in, or are you buying any real estate? Yes No. If yes, state particulars, including number and location of parcels: 11. Do you own, hold, have an ownership interest in, or are you buying any type of motor vehicle? Yes No. If yes, state how many, and particulars: 12. Do you own, hold, have any ownership interest in any of the following types of personal property? If yes, state present value: Yes No Business - $ Yes No Stock in trade, inventory - $ Yes No Office equipment, furnishings - $ Yes No Tools, equipment - $ Yes No Household goods, furnishings - $ Yes No Personal effects, jewelry - $ Yes No Collections (antiques, guns, coins, stamps, records, china, etc.) - $ Yes No Other (specify type and value) - $ If yes on any of the above, explain particulars: 13. Do you own, hold, have any ownership interest in, or are you buying any of the following types of personal property? (If yes, state number and present cash value): Yes No 3

4 Checking account: Savings account: Certificates of Deposit: Mortgage, Promissory Notes: Yes No Shares of stock: Bonds: Partnerships, Joint Ventures: Life insurance, Annuities: IRA s: Undistributed estates, trusts, or conservatorships: Claims, causes of action, judgments: Cash - $ If yes on any of the above, explain particulars: 14. Does anyone owe you any money? Yes No If yes, state particulars and amount: 15. Do you owe any money? Yes No If yes, state particulars, including name of creditor, amount of debt, present monthly payment, balance remaining due: 4

5 16. State the amount of your monthly living expenses: Rent - $ House Payment - $ Food - $ Utilities - $ Transportation - $ Insurance - $ Loans - $ Taxes - $ Clothing - $ Other - $ - Specify: If you live with someone else, do you pay room and board? Yes No If so, how much per month? $ 17. Is there anything else the Court should consider in determining whether you should be provided a lawyer at public expense? Yes No. If yes, state particulars: 18. Would hiring your own lawyer prejudice, jeopardize, or impair your ability to support yourself or your dependents? Yes No 19. Have you in this Questionnaire informed the Court fully, fairly, and completely about your financial situation? Yes No. If no, state particulars: 20. Do you understand that if the Court determines that you are entitled to a public defender, the Court may order the payment of a fee for the public defender as a condition of your probation? Yes No ARE YOUR STATEMENTS MADE IN THIS QUESTIONNAIRE TRUE TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, SO HELP YOU GOD? Yes No Signature Printed name 5

6 Date: Phone: SWORN AND SUBSCRIBED before me on the day of,