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Application For Appointment Of Counsel And Financial Statement Rule 1.1901 Form 8 - Iowa
| Application For Appointment Of Counsel And Financial Statement Form. This is a Iowa form and can be used in Civil District Court Statewide . |
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Rule 1.1901 -- Form 8 February 2002 IN THE IOWA DISTRICT COURT FOR _______________________ COUNTY Plaintiff, v. Defendant. No. ______________________________ APPLICATION FOR APPOINTMENT OF COUNSEL AND FINANCIAL STATEMENT (General) I request that the court appoint counsel to represent me at public expense. I realize that I may be required to repay in whole or in part any public funds expended for this purpose. The following financial statement is submitted in support of my application: Current mailing address: _________________________________________________________________________ Age: _______________________________ Telephone number(s): _______________________________________ Marital status: Single _____________ Married __________ Divorced ____________ Widow(er) _______________ Name of husband/wife: ___________________________________ Live with husband/wife Yes ______ No ______ If no, length of physical separation from husband/wife: _________________________________________________ Number and ages of dependents: ___________________________________________________________________ _____________________________________________________________________________________________ How long a resident of this county: _________________________________________________________________ Occupation: ___________________________________________________________________________________ Present employer: ______________________________________________________________________________ Address: _____________________________________________________________________________________ Former employer: ______________________________________________________________________________ Address: _____________________________________________________________________________________ Weekly take-home (net) earnings: $ ______________________ Weekly gross earnings $ ______________________ Total gross income for past 12 months: $ _____________________________________________________________ Bank with: _________________________________________ Address: __________________________________ Balance personal bank account: $ ___________________________ Balance account in name of husband/wife: $ ___________________________ Balance joint account with husband/wife: $ ___________________________ Balance joint account with any other person(s): $ ___________________________ What is your average monthly living expense (clothing, food, housing, transportation, other)? $ _________________ Does any person pay all or any portion of these expenses: Yes _____ No _____ If yes, who pays these costs and how much do they contribute? ________________________________________________________________________ Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whether registered or titled in your name, name of husband/wife or jointly with another: __________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ List all sources of income, in your name, name of husband/wife or jointly shared with another, including salary (net wages), pensions, bonds, stocks, securities, private business, farming, insurance, retirement benefits, social security benefits, lawsuits or settlements or others: _________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ADC or welfare relief, if any, in your name, name of husband/wife or jointly shared with another: ________________ _____________________________________________________________________________________________ List all sources of public assistance, if any, including ADC, unemployment compensation, heating assistance, food stamps: ____________________________________________________________________________________ _____________________________________________________________________________________________ Real estate owned in your name, name of husband/wife or jointly shared with another (describe): ________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Other assets in your name, name of husband/wife or jointly shared with another (stereo, TV, furniture, trust funds, notes, bonds, stocks savings certificates, life insurance, other): _____________________________________________________________________________________________ _____________________________________________________________________________________________ ___________________________________________ Value: $ ___________________________________________ Are you a beneficiary or heir in an estate of a person deceased? ___________________________________________ List all debts or unpaid bills, including money owed for such things as: Housing, food, clothing, transportation (car, gas), utility costs, medical and dental services and other items, be specific: __________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Does anyone owe you money or have any property belonging to you? _____________________________________ _____________________________________________________________________________________________ Give details in full: _____________________________________________________________________________ _____________________________________________________________________________________________ Do you have a judgment against anyone: Yes __________ No _________ If yes, give name, date, court and amount: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you or anyone else employed or offered to employ an attorney for _____________________________________ in this matter? Yes ___________ No ___________ If so, how much has the attorney been paid by you or for you? $ ____________________________________________________________________________________________ Who can verify this
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