Kansas > Local District Court > 7th Judicial District (Douglas County) > Miscellaneous
Application For Appointed Defense Services - Kansas
| Application For Appointed Defense Services Form. This is a Kansas form and can be used in Miscellaneous 7th Judicial District (Douglas County) Local District Court . |
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APPLICATION FOR APPOINTED DEFENSE SERVICES (TO ACCOMPANY FINANCIAL AFFIDAVIT) STATE VS. _____________________________________________________ OR In RE: _________________________________________________________ District Court Case No. _____________________ County: Douglas NOTICE TO APPLICANT: 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. B. Eligibility for Defense Services 1. Appointed counsel and other defense services will ony be provided to 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 cost of your defense. 4. You must inform the court if there is a change in any of the financial 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 crime must reimbursethe state general fund for all or part of the attorney fees and expenses paid by the Kansas State Board of Indigents Defense Services. K.S.A. 1997 Supp. 21-4610 also provides that persons who are placed on probation or whose sentence is suspended must, as a condition of probation, reimburse the state general fund for all or part of the attorney fees and expenses paid by the Kansas State Board of Indigents Defense Services. 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 been required to pay such sum and who is not willfully in default may petition the sentencing 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 to me and agree to repay the State for the costs of my defense if the court so orders. Date________________ _________________________________________ Signature of the Defendant <<<<<<<<<********>>>>>>>>>>>>> 2 FINANCIAL AFFIDAVIT FOR COURT-APPOINTED ATTORNEY, EXPERT OR OTHER SERVICES (K.A.R. 105-4-3) Judicial District: 7th County: Douglas False statements on this form could result in another case being filed a gainst you. Print clearly. Case No. ___________________________ Name __________________________________________ Age ______ D.O.B. ______ _____ Street Address _________________________________________________________ ______ City _______________________________ State ________________ Zip ______ _________ Telephone No. _________________________ Social Sec. No. ________________ ________ 1. Are you: Self-Employed. What line of work?_____________________________________ __ Employed. Name of employer: __________________________________________ Unemployed. How long unemployed? ____________________________________ 2. List name and address of the places you have worked in the last six months: Employer_______________________________ Address_______________________________ Employer_______________________________ Address_______________________________ Employer_______________________________ Address_______________________________ Employer_______________________________ Address_______________________________ 3. What is your approximate monthly income? $_________________ 4. Spouses Information (include common-law): Name ____________________________________ Spouse is self-employed in ___________________________________ line of work. Spouse is employed by _______________________________________ and earns approximately $__________________ per month. Spouse is currently unemployed and has been since _____________________ ___. 5. Do you own a car, truck, or motorcycle? Yes No Year _______, Make______________, Model____________________ Value $_____ _________ Is it paid for? Yes No Amount owing $____________________ 6. Do you receive, or have you received in the past 6 months, income from rental property, income from a business, public assistance, support, or other sources? Yes No If Yes, give the source and monthly income:_____________________________ ___________ 7. Do you have any money or cash in saving, checking accounts, or other funds? Yes No If Yes, what is the total amount of money available to you? $_____ ________ 8. Do you own a home, land, or other property? Yes, value $_________________ No 9. Can you afford to pay anything toward the costs of your defense at t his time? Yes No If yes, how much? $_________________________ 10. Do you currently have any other court cases pending in the District in which you already have appointed counsel? Yes No Attorney Name___________________________________ <<<<<<<<<********>>>>>>>>>>>>> 3 11. Your current marital status: Single Married Widowed Separated/Divorced 12. How many dependants do you have? ______ List their information be low: Name Age Relationship to You _____________________________ ____ _________________ _____________________________ ____ _________________ _____________________________ ____ _________________ _____________________________ ____ _________________ 13. Monthly Bills Rent/house payment $_________ Food/clothing $_________ Utilities $_________ Alimony $_________ Child support $_________ Installment Payments $_________ Other payments $_________ Total payments $_________ I certify under the penalty of perjury that the foregoing is true and correct. By signing below, I authorize the STATE OF KANSAS to verify my past and present employment earnings, records, bank accounts, stock holdings, and any other asset balances that are needed to process this affidavit with the district court. I further authorize the STATE OF KANSAS to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references. Executed this _________ day of________________, _________. _______________________________ Signature of Applicant ___________________
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