<p> Clerical Use Hold: Yes_ No Bond Info Arresting Agency DOA On View: Yes No Kaufman County Affidavit of Indigence</p><p>This section completed by court personnel only.</p><p>NO. The State of Texas v. In the Court of Kaufman County Offense </p><p>Level </p><p>All information must be complete for consideration. All information must be current, accurate, and true. Intentionally or knowingly giving false information may result in your prosecution for the offense of aggravated perjury, a felony. The punishment for aggravated perjury includes imprisonment not to exceed ten (10) years and a fine not to exceed ten thousand dollars ($10,000). Please fill in all blanks. If you do not know the information being asked, enter “Do not know” in the blank. If the information being asked does not apply to you, enter “N/A” in the blank. YOU MUST REAPPLY EVEN IF YOU HAVE HAD AN ATTORNEY!</p><p>IF YOU APPLIED PRIOR TO BEING RELEASED AND DID NOT RECEIVE CONFIRMATION, YOU MUST CALL THE INDIGENT DEFENSE OFFICE WHEN RELEASED AT 972) 932-0706 TO CHECK ON THE STATUS OF YOUR REQUEST. DO NOT ASSUME THAT AN ATTORNEY HAS BEEN APPOINTED!</p><p>Defendant’s Personal Information Name Phone Number ( ) - . Street Address City, State, Zip </p><p>Social Security - - .</p><p>Driver’s License State Issued Date of Birth / / . Name of Spouse </p><p>Dependent’s Information (Attach Additional Sheet if necessary) 1. Names ______</p><p>Ages ______, Relation ______</p><p>Income (Child Support) ______Relatives or Close Friends</p><p>1. Name</p><p>Address City State Zip Phone Number ( ) - . Relation </p><p>2. Name Address Phone Number ( ) - . Relation </p><p>Employer Information Employer Phone Number ( ) - ext. . Supervisor Street Address </p><p>City, State, Zip </p><p>Hours Worked Per week Per month Pay Rate $ Date Started Spouse’s Employer Street Address </p><p>City, State, Zip </p><p>Hours Worked Per week Per month Pay Rate $______Date Started </p><p>Current Status Do you have an application pending at a mental health facility?</p><p>No Yes Name of Institution Have you been treated for mental illness? No Yes Please include what mental illness? Are you currently in jail? No Yes Name of Institution </p><p>Do you need the services of an interpreter? Yes/No If yes, Language </p><p>Defendant’s Financial Information</p><p>Are you currently receiving any public assistance? (Check all that apply.)</p><p>Food Stamps Medicaid/Medicare/CHIPS Public Hosing TANF SSI</p><p>Other (please list.) </p><p>EXPENSES Monthly amount INCOME Monthly amount Rent or Mortgage Net Pay Auto Payment Spouse’s Net Pay Auto Insurance Tips Home Insurance Dividends Life Insurance Rental Income Health Insurance Pension Pymts Child Care Unemployment Child Support SSI Water Public Assistance Gas Child Support Telephone TANF Electricity Social Security Food Medicaid Medical Cash/Gifts Credit Cards Investment Inc Cable/Internet Alimony Loans Settlement Other Other TOTAL: TOTAL:</p><p>ASSETS: VALUE: Place of Residence ___Own ___Rent ______(Value of Home or Property OR amount of Rent)</p><p>Real Property Owned: Automobiles/Motorcycles/RV’s/Boats (Include any owned or financed within the last two years):</p><p>Make ______Model ______Year ______Make ______Model ______Year ______Make ______Model ______Year ______</p><p>Bank Account Information: Bank Name Type of Account Balance</p><p>______</p><p>Have you attempted to hire an attorney? Yes/No (If Yes, please provide the names of the attorneys you have contacted.) ______</p><p>Please list the names of any individuals that were arrested with you: ______</p><p>On this ______day of ______, 20____, I have been advised of my right to representation by counsel in the trial of 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. By signing below, I swear that all of the above information about my financial condition is current, accurate and true. I understand that a court official can verify any of the information for accuracy as required to determine my eligibility. I further understand that if I knowingly submit any incorrect or false information, or if I knowingly fail to submit any information, I will be denied appointment of counsel and may be subject to criminal prosecution for perjury.</p><p>/ /20 . Applicant’s signature Date</p><p>This defendant is/is not indigent. ______Signature of Judge or Court Designee</p><p>The Court, or the Court’s designee, finds that:</p><p>_____ the defendant is indigent according to the indigency guidelines promulgated by the courts of Kaufman County, or _____ the ends of justice are best served by appointing the defendant an attorney without a finding of indigence, or _____ the court, or the court designee finds that the defendant is not indigent _____ the application is rejected with an opportunity to reapply, re: application is incomplete, ______</p>