Request For Court Appointed Counsel Statement Of Financial Status {CC-7-7-4}

Nebraska State Court Form CC 7:7.4 New 12/15 Neb. Ct. R. § 6-1901(E) REQUEST FOR COURT APPOINTED COUNSEL, STATEMENT OF FINANCIAL STATUS AND AUTHORIZATION FOR RELEASE OF INFORMATION IN CUSTODIAL SANCTION CASES COURT OF __________________COUNTY, NEBRASKA , Plaintiff, IN THE STATE OF NEBRASKA Case No. ____________________ vs. __________________________, Defendant. REQUEST FOR COURT APPOINTED COUNSEL, STATEMENT OF FINANCIAL STATUS AND AUTHORIZATION FOR RELEASE OF INFORMATION IN CUSTODIAL SANCTION CASES I hereby request that the court appoint counsel to represent me because I cannot afford to hire a private attorney. I hereby authorize the court or its representative to have access to any of my financial information including employment status, income records, bank account records, and records of any debts in order to verify the information provided herein. I. A. Full Name: B. Current Address: C. Phone: II. I currently receive the following forms of public assistance. A. Aid to Families With Dependent Children (AFDC) B. Emergency Aid to Elderly, Disabled & Children C. Poverty Related Veteran's Benefits D. Food Stamps E. Medicaid F. Supplemental Security Income G. Refugee Resettlement Benefits H. County General Assistance Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No If You Have Answered Yes to Any of the Above, Stop Here and Sign the Back of this Form. If You Answered No to All Questions, Go on to Section III. Page 1 of 4 Request for Court Appointed Counsel, Statement Of Financial Status and Authorization for Release of Information CC 7:7.4 New 12/15 American LegalNet, Inc. www.FormsWorkFlow.com III. I work at . I earn $ per hr/wk/mo/yr Number of Family Members A. _1_ Self B. Write "1" if married and spouse lives with you. C. Write the number of your children that live with you. Total (add A, B & C) D. If Line "D" is 1 and your annual income is $9,863 or less, check here. If Line "D" is 2 and your annual income is $13,263 or less, check here. If Line "D" is 3 and your annual income is $16,663 or less, check here. If Line "D" is 4 or more and your annual income is $20,063 or less, check here. If you have checked any of the above, stop here and sign the back of this form. If you did not check any of the above, go on to Sections IV., V., & VI. IV. My monthly income is as follows: A. Monthly Take Home Pay From My Job B. Interest and Dividends C. Rental Income D. Unemployment Comp. & Workers' Comp. E. Pensions, Annuities, Social Security F. Other Cash Payments G. Total of A Through F (Total Income) $ $ $ $ $ $ $ V. My share of monthly basic living costs is as follows: A. Rent, House Payment, or Other Shelter Costs . . . . . . . $____________ B. Utilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ C. Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ D. Clothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ E. Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ F. Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ G. Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________ H. Child Support, Alimony, and Other Support . . . . . .. . . . $____________ I. Total of A Through H (Total Expenses) . . . . . . . . . . . .$_________________ Page 2 of 4 Request for Court Appointed Counsel, Statement Of Financial Status and Authorization for Release of Information CC 7:7.4 New 12/15 American LegalNet, Inc. www.FormsWorkFlow.com VI. The value of my liquid assets is as follows: A. Cash, Savings, Bank Accounts . . . . . . . . . . . . . . . . . . . . . B. Stocks, Bonds, Certificates of Deposit . . . . . . . . . . . . . . . C. Real Estate (Assessed Value less Mortgage Balance). . D. Other Personal Property Reasonably Convertible to Cash E. Pensions, Deferred Compensation , IRAs . . . . . . . . . . . . $_____________ $_____________ $_____________ $_____________ $_____________ F. Total Liquid Assets (Add Lines A, B, C, D) . . . . . . . . . . . . . $_______________ I swear or affirm, under penalty of perjury, that the foregoing financial affidavit is true. Signature Date Name Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address STATE OF NEBRASKA COUNTY OF Signed before me on ) ) ss. ) . Witness Page 3 of 4 Request for Court Appointed Counsel, Statement Of Financial Status and Authorization for Release of Information CC 7:7.4 New 12/15 American LegalNet, Inc. www.FormsWorkFlow.com TO BE COMPLETED BY PROBATION STAFF ONLY: Summary: Total Income (from section IV, line G.) . . . . . . . . . . . . . . . . $ Minus Total Expense (from section V, line I.) . . . . . . . . . . . $ = Disposable Net Monthly Income . . . . . . . . . . . . . . . . . . .$ Plus Liquid Assets (from section VI, line F.) . . . . . . . . . . . . $ = Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Minus Bail Obligations (enter as negative number). . . . . . . . $ = Available Funds . . . . . . . . . . . . . . . . . . . . . . . . . . $ Page 4 of 4 Request for Court Appointed Counsel, Statement Of Financial Status and Authorization for Release of Information CC 7:7.4 New 12/15 American LegalNet, Inc. www.FormsWorkFlow.com