Name

County Attorney

Address

City, State, Zip

Telephone Number

Attorney for Plaintiff

MONTANA JUDICIAL DISTRICT COURT, COUNTY

* CAUSE NO.

STATE OF MONTANA, *

* JUDGE

Plaintiff, *

* DEFENDANT'S FINANCIAL

vs. *

* STATEMENT UNDER OATH

, *

* AND REQUEST FOR

Defendant. *

* * * * * * * * * * * * * * * * APPOINTMENT OF COUNSEL

INSTRUCTIONS TO THE DEFENDANT:

The Judge needs to know about your financial situation in determining whether or not you are entitled to have a lawyer appointed to represent you at County expense. Such information will also assist the Judge in determining whether you shall be required to post bail bond, and, if so, the amount of bond. Use care in answering the questions, or you could be subjected to prosecution for false swearing if you knowingly give false or misleading information.

UNDER OATH

The Defendant answers as follows:

EMPLOYMENT STATUS:

1. Are you employed? Yes No

By Whom?

2. Monthly take-home pay is $

3. Any other source of income? (Give details)

ASSETS:

Assets consist of the following:

1. Home or other real property (address or acreage):

Value $

2. Motor Vehicles and/or Mobile Home (describe):

Value $

3. Personal Belongings (summarize):

Value $

4. Cash on hand: $

5. Bank accounts, including checking and savings accounts, Certificates of Deposit, Bonds, Stocks, other: OBLIGATIONS:

1. Outstanding debts and obligations are as follows:

TO WHOM OWED AMOUNT

2. My dependents consist of the following-named individuals: REQUEST FOR A LAWYER

1. Are you requesting the Court to appoint counsel to represent you in this cause for the reason that you are financially unable to hire counsel?

Yes No

If the above answer is "Yes", approximately how much can you afford to contribute toward the expense of a lawyer if one is appointed to represent you in this case?

$

ACKNOWLEDGMENT OF CONSEQUENCES OF GIVING

THE ABOVE INFORMATION UNDER OATH

Under the penalties of a false swearing, I declare that I have examined the above statement made by me and, to the best of my knowledge and belief, each and all are true and correct and have been answered under the oath taken before the Judge as shown below. I also understand that the Court can require me to pay all or part of the compensation and expenses incurred by a court appointed counsel if I am convicted of an offense.

DATED this day of , 19 .

Name

OATH

You, , Defendant herein, do solemnly swear that the information to be set forth in foregoing Defendant's Financial Statement Under Oath and Request for Appointment of Counsel will be the truth, the whole truth and nothing but the truth, so help you God.

Administered on the day of , 19 .

Judge

O R D E R

Based upon the foregoing sworn Affidavit, the Court finds that the Defendant (is) (is not) indigent.

The Court appoints , attorney of

, Montana, as counsel for the Defendant at State expense.

DATED this day of , 19 .

(Court Seal) District Court Judge