Affidavit Of Eligibility And Request For Court-Appointed Counsel For Criminal Non-Support And Probation Violation | Pdf Fpdf Doc Docx | Oregon

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Affidavit Of Eligibility And Request For Court-Appointed Counsel  For Criminal  Non-Support And Probation Violation | Pdf Fpdf Doc Docx | Oregon

Affidavit Of Eligibility And Request For Court-Appointed Counsel For Criminal Non-Support And Probation Violation

This is a Oregon form that can be used for Criminal within Local County, Marion, Circuit Court.

Alternate TextLast updated: 5/18/2006

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S T AT E O F OR E GO N Ma rion C oun ty Ca se N o.: Cha rge(s): STATE OF OREGON, PLAINTIFF AFFIDAVIT OF ELIGIBILITY AND REQUEST FOR COURT-APPOINTED COUNSEL FOR CRIMINAL NON-SUPPORT AND PROBATION VIOLATION (No n-paym ent of fee s cases only) V. DEFENDANT I am asking for appointment of an attorney in this case because I cannot pay for an attorney now without causing substantial hardship to myself or my dependent family. The following information is complete and accurate to the best of my knowledge, and I ask the court to use the information to decide whether I or my child can have an appointed attorney and payment of other defense costs at public expense. I understand that I can be required to document or verify this information. I understand that failure to do so could result in my request being denied, or if counsel has already been appointed, the withdrawal of counsel. I understand that if I do not tell the truth, I can be required to repay the cost to the state for providing court-appointed counsel and/or I can be charged with a crime, and if convicted, I can be incarcerated. BE SURE TO READ THE "ADVICE OF RIGHTS" FORM P L E A S E PR I N T C L E A R LY A N D C O M P L E TE E V E R Y LI N E B E L O W T H A T I S A P P L IC A B L E TO Y O U ­ IF S O M E T H IN G D O E S N O T A P P L Y , W R I T E " N A " Full Nam e F IR S T MIDDLE LAST Address STREET ADDRESS Telephone No. ( C I TY S T A TE ZIP ) AREA CODE Date of Birth MONTH / DAY / YEAR Sex: 9 Female 9 Ma le Social Sec urity No. 9 Married 9 Single 9 Separated 9 Divorced 9 Other Re lationship List the following information for everyone living in your household: Name Re lationship N am e Have you ever requested a court-appointed attorney before this application? If "yes," which county? Date Charge(s ) 9 Yes 9 No Have you ever been denied a court-appointed attorney? If "yes," which county? Date 9 Yes 9 No Charge(s ) I understand that I may be required to pay a $20 application fee for the processing of this application. If I receive the services of a court-appointed attorney, I understand that I may be required to pay a contribution amount and/or I may be required to reimburse the state for reasonable court-appointed attorney fees and costs regardless of the outcome of the case. Any order for payment of these fees or costs will be based upon my financial ability to pay such fees and costs. I understand I may request the court waive all or part of the potential fees and costs. I acknowledge receipt of the Advice of Rights form by initialing as follows: . I certify and affirm that I have read the information contained in this form, personally completed this application or requested its completion, and that all statements contained herein are true and complete. DATE S IG N A T U R E O F A P P L IC A N T 9 Applicant has completed this affidavit. SUBSCR IBED AND SW ORN TO before me this 9 Applicant has requested or allowed court / release office personnel to complete affidavit utilizing information the applicant has provided. day of , 200 . AFIN IDEF-202:6/04 CLERK OF COURT EVT # American LegalNet, Inc. www.USCourtForms.com

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