Eligibility Determination For Indigent Defense Services {9-403}

9-403. Eligibility determination for indigent defense services. [Section 31-15-7 NMSA 1978. For use in the District Court, Magistrate Court and Metropolitan Court] STATE OF NEW MEXICO COUNTY OF___________________ _______________________ COURT KEY___________ [STATE OF NEW MEXICO] [COUNTY OF __________________] v. No. __________ ________________________________, Defendant ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICES Name: _______________________________________________ DOB: _________ Age: ______ AKA:______________________________________ Sex: Male Female SSN: ________________ Address: _________________________________________________ Phone: __________________ Charges: ___________________________________________________________________________ Lives alone:____ Lives with: Spouse ____ Children ____ Parent ____ Friend ____ Other ______ Marital status: Single ____ Married ____ Divorced ___ Separated ____ Widowed ______ Number of dependents in household: ___________ [ ] Defendant is in jail. [ ] Defendant is not in jail. PRESUMPTIVE ELIGIBILITY: ___ ___ I currently DO NOT receive public assistance. I currently receive the following type of public assistance in ________________ County: DEPARTMENT OF HEALTH CASE MANAGEMENT SERVICES (DHMS) $________ TANF/GA $________ Food Stamps $_________ Medicaid $_________ Public Housing $_____________ SSI/SSDI $ _______ VA Disability ___________ ___ Unable to complete application because of possible Mental Health/Developmental Issue of applicant. NET NCOME: Employer's Name Employer's Phone SELF _________________ _________________ SPOUSE _________________ _________________ American LegalNet, Inc. www.FormsWorkFlow.com Pay Period (weekly, every second 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 INCOM E $________________ + __________=____/____/____A ASSETS: CASH ON HAND BANK ACCOUNTS REAL ESTATE (equity) $_______________ $_______________ $_______________ $_______________ MOTOR VEHICLES (equity) $_______________ $_______________ OTHER PERSONAL PROPERTY (equity): (describe and set forth equity) ______________________ ______________________ $_______________ $_______________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ SCREENING USE ONLY _________ = ____/____/____B TOTAL ASSETS $________________ + EXCEPTIONAL EXPENSES (total exceptional expenses of dependents): MEDICAL EXPENSES (not covered by insurance) $____________ MEDICAL INSURANCE PAYMENTS (receipts required) $____________ COURT-ORDER SUPPORT PAYMENTS/ALIMONY $____________ CHILD-CARE PAYMENTS (e.g. day care) $____________ OTHER (describe) _____________________________ $____________ ______________________________________________ $____________ SCREENING USE ONLY $__________ = ____/____/____C TOTAL EXCEPTIONAL EXPENSES I UNDERSTAND THAT IF IT IS DETERMINED THAT I AM NOT INDIGENT, I MAY APPEAL TO THE COURT WITHIN TEN (10) DAYS AFTER THE DATE I AM ADVISED American LegalNet, Inc. www.FormsWorkFlow.com OF THIS DECISION. ____ I wish to appeal. ____ I do not wish to appeal. STATE OF NEW MEXICO ) ) ss COUNTY OF _________________ ) This statement is made under oath. I hereby state that the above information regarding my financial condition is correct to the best of my knowledge. I hereby authorize the screening agent, district defender and the court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies. ____________________ Date STATE OF NEW MEXICO ) ) ss COUNTY OF __________ ) Signed and sworn to (or affirmed) before ______________________ (name of applicant). me on _____________ (date) by ___________________________________ Signature of applicant ________________________________ Notary (Seal, if any) My commission expires: ____________ COLUMN "A" (net income) plus COLUMN "B" (assets) SCREENING USE ONLY minus COLUMN "C" (exceptional expenses) AVAILABLE FUNDS equals AVAILABLE FUNDS ............................................. =/___________ ____ ____ ____ The applicant is indigent. The applicant is not indigent. The applicant [has] [has not] paid the $10.00 application fee. Receipt number: __________________ Based on the above answers and information, I find that the applicant [is] [is not] indigent. _________________________________ Signature of Screening Agent ____________________________ Title (Complete the following only if the court has determined that the applicant is unable to pay the $10.00 application fee). American LegalNet, Inc. www.FormsWorkFlow.com _____ I find that the applicant is unable to pay the$10.00 indigency application fee, due to the following reason _____________________________________________ and I therefore waive the payment of the $10.00 application fee. ___________________________________ Signature of Screening Agent GUIDELINES FOR DETERMINING ELIGIBILITY Pursuant to Section 31-15-7 NMSA 1978, the following guidelines are established for determination of indigency and eligibility for public defender services. I. APPLICATION FEE A person shall pay a non-refundable application fee for each case in the amount set in Section 35-15-12 NMSA 1978 at the time the person applies with the public defender for representation. The interviewer will determine if the financial circumstances of the applicant are such that the fee would pose an exceptional hardship, and will recommend to the District office Administrator or Eligibility Supervisor if the fee should be waived. The interviewer will document on the application the reason for the fee waiver. II. PRESUMPTION OF INDIGENCY An applicant is presumed indigent if the applicant is a current recipient of state or federally administered public assistance programs for the indigent: temporary assistance for needy families (TANF), general assistance (GA), supplemental security income (SSI), social security disability income (SSDI), Veteran's disability benefits (VA) if the benefit is the sole source of income, food stamps, medicaid, public assisted housing or Department of Health, Case Management Services (DHMS). Proof of assistance must be attached to the application and no further inquiry is necessary. The document su