Kansas > Local District Court > 4th Judicial District > Criminal
Application For Appointed Defense Services - Kansas
| Application For Appointed Defense Services Form. This is a Kansas form and can be used in Criminal 4th Judicial District Local District Court . |
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APPLICATION FOR APPOINTED DEFENSE SERVICES (To accompany Financial Affidavit) STATE VS. _______________________________ DISTRICT COURT CASE NO. ______ _______ Or IN RE:____________________________________ COUNTY ______________________ _______ NOTICE TO APPLICANT: ANY DEFENDANT CHARGED WITH A FELONY VIOLAT ION, ENTITLED TO AN ATTORNEY PURSUANT TO K.S.A. 22-4503, IS REQUIRED BY LAW TO PA Y A $50 BOARD OF INDIGENTS DEFENSE SERVICES APPLICATION FEE, UNLESS THE FEE IS WAIVED BY TH E COURT. THE FEE IS TO BE PAID TO THE CLERK OF THE DISTRICT COURT. FAILURE TO PAY THIS FEE MAY BE CONSIDERED A VIOLATION OF THE CONDITIONS OF YOUR RELEASE AND YOUR BOND MA Y BE REVOKED FOR FAILURE TO PAY SAID APPLICATION FEE. A. GENERAL INFORMATION 1. The information on the attached affidavit is not confidential. 2. Any information contained on the attached affidavit may be verified by the judge or the Kansas Board of Indigents Defense Services. 3. False entries may lead to criminal prosecution and conviction. 4. If you do not understand a specific question or need help, ask for assistance. 5. The judge may place you under oath and inquire further about any information provided on this form. A. ELIGIBILITY FOR DEFENSE SERVICES 1. Appointed counsel and other defense services will only by provided t o people who cannot afford to pay for these services themselves. 2. If the judge determines that you are able to pay a part of the costs of your defense, you will be found partially indigent and the court will order you to pay for a part of these costs. 3. If, after the date of the alleged offense, you transfer any of your property for less than it is worth, the State may sue to obtain repayment of the co st of your defense. 4. You must inform the court if there is a change in any of the financi al information given on the affidavit. C. REPAYMENT TO THE STATE K.S.A. 1997 Supp. 21-4603 provides that persons who are convicted of a c rime must reimburse the state general fund for all or part of the attorney fe es and expenses paid by the Kansas State Board of Indigents Defense Service s. K.S.A. 1997 Supp. 21-4610 also provides that persons who are placed on probatio n or whose sentence is suspended must, as a condition of probation, reimburse the s tate general fund for all or part of the attorney fees and expenses paid by t he Kansas State Board of Indigents Defense Services. <<<<<<<<<********>>>>>>>>>>>>> 2 The court shall take into account the financial resources and the nature of the burden that payment of such sum will impose. Any person who has bee n required to pay such sum and who is not willfully in default may petition the sen tencing court to waive payment of any remaining balance or portion thereof. I have read or have had read to me and understand the above notice. I h ereby request that court-appointed counsel be provided tome and agree to attem pt to repay the State for the costs of my defense if the court so orders. ________________________ ________________________________________________ Date Signature of Defendant FINANCIAL AFFIDAVIT For court-appointed attorney, expert or other services (K.A.R. 105-4-3) Judicial Dist. ________________ County ____________________ Case No. _____________ FALSE STATEMENTS COULD RESULT IN ANOTHER CASE BEING FILED AGAINST YOU. Name ______________________________ Age____ D.O.B. _________Phone ______ ______ S.S.#___________ Address ____________________________ City ___________________ State ____ _________ Zip Code _______ Spouse (If married-including common- law)__________________________________________________________ 1. Are you Self-Employed Employed Unemployed If self-employed, what line of work? ________________________________________________________ If employed, who do you work for? _________________________________________________________ If unemployed, for how long? _____________________________________________________________ 2. List the places you have worked in the last six months: 1. Name ______________________________ Address ______________________________________ 2. Name ______________________________ Address ______________________________________ 3. Name ______________________________ Address ______________________________________ 3. If employed, give an approximate monthly rate of pay __________________________________________ 4. Is your spouse Self-Employed Employed Unemployed <<<<<<<<<********>>>>>>>>>>>>> 3 If self-employed, what line of work? ________________________________________________________ If employed, who does he/she work for?_____________________________________________________ If employed, give an approximate monthly rate of pay __________________________________________ If unemployed, for how long? _____________________________________________________________ 4. Do you own a car, truck or motorcycle? Yes No If yes, give year, make and model: _________________________________________________________ Please give value __________________ Is it paid for? Yes No Amount owing _________________ 4. Do you receive, or have you received, in the past six month, income from rental property, public assistance, support, or other sources, including from a business? Yes No If yes, give source and monthly income: _____________________________________________________ 4. Do you have any money or cash in savings, checking accounts or other fun ds? Yes No If yes, list amount of money available to you _________________________________________________ 4. Do you own a home, land or other property? Yes No If yes, give value _____________________ 4. Can you afford to pay anything toward the costs of your defense at this time? Yes No If yes, how much ______________________________________________________________________ 4. Do you currently have any other court cases pending in the District, in which you already have counsel appointed? Yes No If yes, give attorneys name _____________________________________________________________ (Check One) MARRIED SEPARATED/ DIVORCED SINGLE WIDOWED <<<<<<<<<********>>>>>>>>>>>>> 4 DEPENDENTS MONTHLY BILLS TOTAL NUMBER RENT/HOUSE PAYMENT ______________ _________ LIST NAME, AGES AND FOOD/CLOTHING RELATIONSHIP TO YOU _______________ _________________________ UTILITIES ___ _____________________ _________________________ ALIMONY ___ _____________________ _________________________ CHILD SUPPORT ___ _______________ _________________________ INSTALLMENT PAYMENTS ___ _________________________ __ OTHER PAYMENTS _____________ TOT
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