New Hampshire > Statewide > Superior Court > Criminal
Financial Affidavit And Application For Court Appointed Counsel NHJB-2313-DSSup - New Hampshire
| Financial Affidavit And Application For Court Appointed Counsel Form. This is a New Hampshire form and can be used in Criminal Superior Court Statewide . |
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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL RSA: Check Case Type: Homicide Misdemeanor Felony (Non Homicide) Juvenile Other Misdemeanor Appeal Supreme Court Appeal This form must be filled out completely. If an item does not apply to you enter N/A. In this affidavit & application you will swear that all the information is correct and state "I understand that I may be required to repay the services provided me by court appointed counsel unless the court finds that I am or will be financially unable to pay." Name: Address: Telephone: Marital Status a. b. Soc. Sec. No: Date of Birth: Single Married Divorced c. d. YOURS (A) $ $ $ $ $ Age Separated Widowed List dependents you personally support: (Include address if not same as yours. List relationship & age) 1. AVAILABLE MONEY a. Cash on Hand .............................................................. b. Checking Accounts ...................................................... c. Savings Accounts ........................................................ d. Stock, Bonds, Trusts, CD's, Other (CSVLI etc.) .......... TOTALS 1: 2. INCOME a. Salary/Wages Take home pay (weekly b. Alimony or Maintenance Received (weekly c. Child Support Received (weekly 3. EMPLOYMENT YOURS a. Employer: b. Address: Check: Full Time SPOUSES (B) $ $ $ $ $ $ $ $ $ x 4.333=) $ x 4.333=) $ x 4.333=) $ TOTALS 2: $ SPOUSES Part Time Seasonal Full Time Part Time Seasonal 4. HOUSING COSTS a. Monthly Rent or Mortgage ........................................................................... $ b. Utilities (Electricity, heat, etc) ....................................................................... $ TOTALS 4: ................................. $ NHJB-2313-DSSup (02/04/2011) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL 5. MONTHLY LOAN PAYMENTS (List only loans and regular payments not listed elsewhere. NOT for monthly living expenses.) Name Purpose Still Owe $ $ Monthly Payment $ $ TOTALS 5: ................................. $ 6. OTHER PAYMENTS - Alimony Paid, Child Care, Support Name Purpose Still Owe $ $ Monthly Payment $ $ TOTALS 6: ................................. $ 7. PROPERTY a. Do you own a house or other real estate) Who holds mortgage Yes (if yes, list) No Market Value $ Mortgage Owed $ b. Have you sold or transferred any real estate or personal property worth $200 or more in the last 6 months? Yes (if yes list) No Property To Whom Transferred Value Amount Received $ $ $ $ 8. REMARKS PLEASE READ THIS CAREFULLY! Initial each box to show that you have read and understand this application. I request that the court appoint an attorney to represent me in defense of the charges against me as I can not afford to retain private counsel. I understand that if an attorney is appointed to represent me, I shall be liable for all legal fees and any other court approved costs of my defense and will be ordered to repay the state according to my ability which will be determined by the Office of Cost Containment (OCC). I understand that I must contact OCC within 5 days to confirm my mailing address, verify my ability to repay and make ongoing payment and contact arrangements. I understand that if I do not agree with the eligibility findings or ability to repay decisions made by OCC, I may appeal to the court but must prove to the court that any claimed shortage of funds is total or permanent or future employment is unlikely. I understand that I am required to notify the OCC and the court of every change of address while I still owe the state for the cost of my representation. I further understand that if at any time prior to the disposition of my case, my financial condition changes, I must notify the Court and OCC immediately. I swear that the foregoing information and answers are true to the best of my knowledge and are given to induce the state to appoint counsel to represent me because I am currently unable to retain private counsel. I have made the statements on the financial affidavit and understand that I make them under the penalty of perjury the punishment for which is imprisonment for not more than seven years. This has also been explained to me by a court officer. NHJB-2313-DSSup (02/04/2011) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL AUTHORIZATION FOR THE RELEASE OF INFORMATION To whom it may concern: I hereby authorize the State of New Hampshire, Office of Cost Containment, to obtain any and all information with regard to my employment and financial condition from government agency, bank, creditor or employer. Date Applicant Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any FOR COURT USE , County of by Signature of Notarial Officer / Title Application Approved: If approved this form and NE/NFL required send to OCC. Application Denied: If denied send this form to OCC. NE/NFL not required. Date Presiding Justice (Signature required only if application denied) NHJB-2313-DSSup (02/04/2011) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT & APPLICATION FOR COURT APPOINTED COUNSEL Financial Affidavit Worksheet Enter totals listed on front of form. STEP ONE. Market Value of Property Mortgage Owed 7A. $ 7B. (-) $ 0.00 NET VALUE OF REAL ESTATE ................ > $ If value of real estate is equal to or greater than the amount listed on Financial Eligibility Table (OCC Fm2) then the defendant is "INELIGIBLE" for indigent defense funds. Proceed to next step regardless of results. STEP TWO. Available Money Monthly Income 1A. $ 1B. (+) $ 2A. (+) $ 2B. (+) $ TOTAL PART ONE ............................................. > Line A $ Housing Costs Monthly Loan Payments Other Payments Minimum Living Exp (Individual) # Listed Dependents x $100.00 0.00 4. $ 5. (+) $ 6. (+) $ (+) $ (+) $ 250.00 0.00 250.00 TOTAL PART TWO ............................................ > Line B $ TOTAL FUNDS AVAILABLE FOR REPRESENTATION Line A minus Line B ...... > Line C $ -250.00 If available funds for representation is equal to or greater than the amount listed on Financial Eligibility Table (OCC Fm 2) then the defendant is "INELIGIBLE" for indigent defen
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