Maine > Statewide > District Court > Civil And Family Matters
Preliminary Motion For Assignment Of Counsel, Affidavit And Release - Maine
| Preliminary Motion For Assignment Of Counsel, Affidavit And Release Form. This is a Maine form and can be used in Civil And Family Matters District Court Statewide . |
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STATE OF MAINE SUPERIOR COURT _________________________, ss Docket No. ____________________ DISTRICT COURT Location ______________________ Docket No. ____________________ STATE OF MAINE /_________________________ vs Defendant PRELIMINARY MOTION FOR ASSIGNMENT OF COUNSEL, AFFIDAVIT AND RELEASE MOTION & AFFIDAVIT I request the Court to assign an attorney for me at public expense, based on the following accurate information. Mailing Address Date of Birth Home Phone Cell Phone Work Phone Income: Salary and wages (gross pay) $ OR hourly wage $ Source of income/employer is: Employer (name & address) Unemployment Social Security TANF Alimony/child support week Other biweekly month other OR Assets: Cash bail I posted (1st party) in this or any other case $ Cash on hand $ Cash in the Bank $ Money owed to me $ Property worth more than $250 (include property owned alone or with any other person): House $ Car $ Real Estate $ Stocks $ Expenses (Monthly) Mortgage $ Cable $ Rent $ Child Support $ Credit Card $ Cell Phone $ Utilities $ Loans $ Other $ RV $ Food$ Heat $ Other $ per bi-weekly month Other $ Check the following that apply I have (number) children who live with me for whom I pay support of $ I live alone with another who is my spouse friend parent(s) other: That person shares my living expenses and contributes $ per week other I acknowledge that disclosure of my Social Security account number is mandatory under 36 M.R.S. ยง5276-A. My Social Security account number may be used to facilitate the collection of money that I may owe the State of Maine as a result of having had an attorney assigned to represent me if it is later determined that I am to be responsible for all or part of the attorney fees and costs. SS Number Disclosure Required on separate form I furnish the above information to support my request for assignment of counsel to represent me with regard to the pending charges. I have read the above form, I understand it, and the answers to the questions are true. I understand that any false answers on this form may subject me to criminal prosecution. I understand and agree that further investigation may be conducted, if necessary, to verify the information I have provided. I also understand that I have a continuing obligation, personally and through counsel, to report to the court and/or to the Maine Commission on Indigent Legal Services any changes in my employment or other financial circumstances. Date: Signature of Defendant Subscribed and sworn to before me. Notary, Clerk, Attorney, Judge/Justice ORDER Motion Denied Defendant is not indigent There is no risk of jail Motion Granted Attorney assigned to represent defendant Motion Granted: Defendant is partially indigent; and Defendant shall pay toward attorney's fees as follows: $ per week month biweekly other: up to a total of $ , starting . Maine Commission on Indigent Legal Services to determine rate of reimbursement. ANY FIRST-PARTY BAIL MAY BE APPLIED TO OFFSET COUNSEL FEES Attorney is assigned to represent Defendant This ORDER may be reviewed and revised at any time based on new or different information. REFER TO SCREENER: YES NO Date: CR-032, Rev. 10/10 Judge/Justice American LegalNet, Inc. www.FormsWorkFlow.com
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