Download Motion for Appointment of Counsel

INTAKE DATE:
_________________
COURT: ___________________________
APPT DATE:
__________________
HEARING DATE: ___________________________
HEARING TIME:
_____________________
MOTION FOR APPOINTMENT OF COUNSEL
_____________________
STATE OF TEXAS
VS.
CASE NO.:
SO#:
NAME: ______________________________________________
OFFENSE: _____________________________
_________________________
ARREST DATE:
________________
STATUS:______________________________
BONDSMAN: ______________________________
AMOUNT: ______________________________
OTHER PENDING CHARGES:
PRESENT ADDRESS:
________________________________________
TEL #:
______________________
LENGTH OF TIME AT THAT ADDRESS:
SOC.SEC NO: ________ DOB:______
AGE:_____ YRS. SEX:_______
MILITARY DISCH::
EDUCATION LEVEL:
MARITAL STATUS: S / M / D / W
NAME OF SPOUSE:
NO. OF DEPS:
AGES:
(DEFENDANT) EMPLOYED: YES / NO OCCUPATION:
.
NAME OF EMPLOYER:
ADDRESS:
.
YEARS EMPLOYED:
HRS/WEEK:
$/HR:
AMOUNT OF WKLY / BIWKLY INCOME / TAKE
HOME PAY $
IF UNEMPLOYED PREVIOUS OCCUPATION:
.
PREVIOUS EMPLOYER:
LENGTH OF TIME UNEMPLOYED
.
SPOUSE / PARENT(S) EMPLOYED: YES / NO OCCUPATION:
.
NAME OF EMPLOYER:
ADDRESS:
.
YEARS EMPLOYED:
HRS/WEEK:
$HR:
AMOUNT OF WKLY / BIWKLY INCOME / TAKE
HOME PAY: $
IF UNEMPLOYED PREVIOUS OCCUPATION:
.
PREVIOUS EMPLOYER:
LENGTH OF TIME UNEMPLOYED:
.
AMOUNT OF RENT$
AMT OF CAR PYMT $
YEAR/MODEL:
AMOUNT PD FOR CHILDCARE $
ANY EXCESSIVE MEDICAL EXPENSES? YES / NO
AMOUNT OF PYMT $
DO YOU RECEIVE / PAY CHILD SUPPORT $
DO YOU RECEIVE AFDC/TANF:$
FOOD STAMPS: $
SOC.SEC.: $
SSI: $
WORKMANS COMP: $
UNEMPLOYMENT BENEFITS: $
INCOME PRODUCING PROPERTY $
SAVINGS ACCT: $
NET VALUES:
HOME: $
CAR: $
OTHER INCOME: $
CASH MONEY: $
ASSETS (SPECIFY)
HAVE YOU APPLIED FOR APPOINTED COUNSEL BEFORE? YES / NO
NAME OF PREVIOUS ATTY:
YEAR
EMERGENCY CONTACT:
PHONE #
RELATION
TOTAL INCOME:
$
CAR PAYMENT:
RENT PAYMENT:
CHILD SUPPORT:
CHILDCARE:
EXCESSIVE MEDICAL BILLS:
TOTAL:
$
FAMILY SIZE
I HAVE BEEN ADVISED BY THE
COURT OF MY RIGHT TO REPRESENTATION BY COUNSEL IN THE TRIAL OF THE
CHARGE PENDING AGAINST ME. I HAVE NO ABILITY TO OBTAIN CREDIT TO RAISE FUNDS WITH WHICH TO EMPLOY AN
ATTORNEY AND DESIRE THAT THE COURT APPOINT AN ATTORNEY TO DEFEND ME (ARTICLE 26.04). ANY MISREPRESENTATION
OF THIS INFORMATION TO THE COURT MAY BE GROUNDS FOR FURTHER ACTION AGAINST YOU. I, THE UNDERSIGNED, BEING
DULY SWORN DEPOSE AND SAY UNDER PENALTY OF PERJURY, THAT THE FACTS CONTAINED HEREIN ARE TRUE AND
CORRECT. I HEREBY AUTHORIZE ANY PERSON, ORGANIZATION, OR ESTABLISHMENT HAVING INFORMATION OR RECORDS
CONCERNING ME OR MY CIRCUMSTANCES, TO FURNISH SUCH INFORMATION TO A REPRESENTATIVE OF THE EL PASO COUNTY
INDIGENT DEFENSE CERTIFICATION PROGRAM. IF YOU QUALIFY FOR COURT APPOINTED COUNSEL, YOU MAY BE REQUIRED TO
REIMBURSE THE COUNTY FOR ATTORNEY FEES AND OTHER COSTS.
SWORN TO AND SUBSCRIBED TO BEFORE ME THIS
OF
, 20____.
DEFENDANT’S SIGNATURE
QUALIFIES:
YES / NO
NOTARY PUBLIC, STATE OF TEXAS (CASEWORKER)
INTERPRETER:
YES / NO