Application For Appointment Of Counsel And Financial Statement (Juvenile Proceedings) {Rule 8.33 Form 3}

Rule 8.33 -- Form 3 February 2002 IN THE IOWA DISTRICT COURT FOR ________________________ COUNTY IN THE INTERESTS OF ____________________________________, A Child. No. ______________________________ APPLICATION FOR APPOINTMENT OF COUNSEL AND FINANCIAL STATEMENT (Juvenile Proceedings) I, __________________________________________________, state that I am the (parent) (guardian) (custodian) of ____________________________________________________, a child, and request that the court appoint counsel to represent (me) (the child) 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): _______________________________________________ Martial 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 banking 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): ________________ _____________________________________________________________________________________________ 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: $ __________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Are you a beneficiary or heir in an estate of a person deceased? ___________________________________________ List all debts or unpaid bills, including money owned 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 (you) (the child) in this matter? Yes ________ No ________ If so, how much has the attorney been paid by you or for you? $ _______________________________ Who can verify this information: ___________________________________________________________________ Telephone number: _______