New Mexico > Local District Court > 11th Judicial District > San Juan County > Criminal
Eligibility Determination For Indigent Defense Services - New Mexico
| Eligibility Determination For Indigent Defense Services Form. This is a New Mexico form and can be used in Criminal San Juan County 11th Judicial District Local District Court . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
ELEVENTH DISTRICT COURT STATE OF NEW MEXICO COUNTY OF SAN JUAN STATE OF NEW MEXICO VS. NO. ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICES NAME: DOB: AGE AKA: SEX: M F SS#: ADDRESS: PHONE: CHARGES: DC# MC# +), +), +), +), +), +), LIVES ALONE:.)- WITH: SPOUSE.)- CHILDREN.)- PARENT.)- FRIEND(S).)- OTHER.)- +), +), +), +), +), +), MARITAL STATUS:.)- SINGLE .)- MARRIED .)- DIVORCED .)- SEPARATED .)- WIDOWED.)- NUMBER OF FAMILY IN HOUSEHOLD: PRESUMPTIVE ELIGIBILITY: +), .)- I currently do not receive public assistance. +), .)- I currently receive the following type of public assistance in COUNTY +), .)- AFDC $ Food Stamps $ Medicaid $ SSI $ +), .)- Other (specify type and amount): NET INCOME: SELF FAMILY IN HOUSEHOLD Employers Name Employers Phone Pay period (weekly, every 2nd week, twice monthly, monthly) Net take home pay (salary/wages minus deductions required by law) $ $ Other income sources (please specify) $ $ SCREENING $ $ USE ONLY TOTAL ANNUAL INCOME $ + $ =/ / A ASSETS: Cash on hand $ $ Bank Accounts $ $ Real estate Equity $ $ Equity $ $ Motor Vehicles Equity $ $ Equity $ $ Other Personal Property (described): Equity $ $ SCREENING Equity $ $ USE ONLY TOTAL ASSETS $ + $ =/ / B EXCEPTIONAL EXPENSES (Total exceptional expenses of family) Medical Expenses (list only unusual and continuing expenses) $ Court-order support payments/alimony $ Child-care payments (e.g.,day care) $ Other (describe): ) $ SCREENING ) $ USE ONLY TOTAL EXPENSES $ =/ / C *P/G/C means parents(s)/guardian/custodian. <<<<<<<<<********>>>>>>>>>>>>> 2STATE OF NEW MEXICO COUNTY OF SAN JUAN This statement is made under oath; any false statement of a material fact to any question contained herein shall constitute perjury. I hereby state that the above information is correct to the best of my knowledge. I hereby authorize the screening agency, District Defender, and/or courts to obtain information from financial institutions, employers and/or the I.R.S. regarding my financial condition. DATE SIGNATURE OF DEFENDANT SWORN/AFFIRMED AND SIGNED BEFORE ME THIS DAY. DATE SIGNATURE AND TITLE MY COMMISSION EXPIRES COLUMN "A"(NET INCOME) PLUS COLUMN "B"(ASSETS) SCREENING USE ONLY MINUS COLUMN "C"(EXCEPTIONAL EXPENSES) AVAILABLE FUNDS EQUALS AVAILABLE FUNDS....................................=/ /INDIGENCY TABLE: HOUSEHOLD SIZE(SELF & FAMILY ONLY) 1 2 3 4 AVAILABLE FUNDS(ANNUALLY) $8,512 $11,487 $14,462 $17,437 ADD $2.975.00 FOR EACH ADDITIONAL FAMILY MEMBER. THE DEFENDANT IS INDIGENT THE DEFENDANT IS NOT INDIGENT. SIGNATURE OF SCREENING AGENT TITLE Based on the above answers and information, I find that the DEFENDANT (is)(is not) and indigent person and that an attorney on contract with the Public Defender Department (shall)(shall not) represent the defendant in the above entitled case. JUDGE
|
|||||||
