REQUEST FOR ATTORNEY/AFFIDAVIT OF INDIGENCE-CRIMINAL CASE

REQUEST FOR ATTORNEY/AFFIDAVIT OF INDIGENCE
Defendant's Name
Date of Birth
Case No/Court
Bond Co
Defendants Email
example@example.com
Defendant's Phone
Format: (000) 000-0000.
Defendants Mailing Address
Alternative Contact Information
Martial Status (if separated, check "single")
NUMBER of my own CHILDREN less than 18 years old who live primarily with me
BENEFITS: I, my spouse or my children who live with me, receive any of the following: FoodStamps, Medicaid, Disability, TANF, SSI, or Housing Assistance:
JAIL/COMMITTED: I am in jail or prison serving a sentence; residing in a public mental health facility; or subject to a mental health commitment proceeding:
MY HOUSEHOLD INCOME INCLUDES:
My job status (choose all that apply)
In an average week I work:
Hours

My Household income Includes:

Rows	Amount	Per(hour/week/bi-weekly/monthly)	Notes (average weekly hours or how long unemployed)
My primary Job
My second Job
My other income
My spouse's Income
I am presently UNEMPLOYED and have been for

Do you Receive Child Support?
If you receive child support, how much do your receive a month?
If you pay child support, how much do you pay a month?
SPECIAL CIRCUMSTANCES/HARDSHIPS the Judge/RCMAC Director should consider:
"On this day of (today's date), I have been advised by this Court of my right to representation by counsel in connection with the charge pending against me. I am without means to employ counsel of my own choosing and I hereby request the court to appoint counsel for me." TX CCP Art. 26.04(o).
Today's date

MonthDayYear
Date
By signing below, you understand that you are under oath and swearing to: "On this day of (today's date), I have been advised by this Court of my right to representation by counsel in connection with the charge pending against me. I am without means to employ counsel of my own choosing and I hereby request the court to appoint counsel for me." TX CCP Art. 26.04(o).

Clear
Date

MonthDayYear
Date
SWORN and SUBSCRIBED before me:
Should be Empty:

REQUEST FOR ATTORNEY/AFFIDAVIT OF INDIGENCE