Indigent Attorney Application
If you are required to fill out an application, do not sign it before you bring it to the Municipal Court. A clerk must witness the signature and swear the defendant in. Please bring proof of income with the application.
STATE OF NEW MEXICO CITY OF ALAMOGORDO
IN THE MUNICIPAL COURT
CITY OF ALAMOGORDO
v. NO. ______________
_________________________
Defendant
ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICES
NAME: ________________________________________ D.O.B.: ___________________
AGE: ____________
AKA: ________________________ SEX: M F SS#: __________________________
ADDRESS: ____________________________ PHONE: __________________________
CHARGES:_______________________________________________________________________
DC# ________________________________ MC# __________________________________
LIVES ALONE: ____ 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) ____
AFDC $________ Food Stamps $________ Medicaid $________ DSI $________ Public Housing $________
ATTACH PROOF OF PUBLIC ASSISTANCE
Employed ______________ Unemployed ______________
| NET INCOME: | SELF | SPOUSE |
| Employers Name: | _________________________ | _________________________ |
| Employers Phone | _________________________ | _________________________ |
| Pay period (weekly, every 2nd week, twice monthly | ||
| $_________________________ | $_________________________ | |
| Net take home pay (salary/wages minus deductions required by law) | ||
| $_________________________ | $_________________________ | |
| Other income sources (please specify) ____________________________ | ||
| $_________________________ | $_________________________ | |
| TOTAL ANNUAL INCOME | $____________ + $____________ = ____________/A | |
| ASSETS: | SELF | SPOUSE |
| Cash on Hand | $_________________________ | $_________________________ |
| Bank Accounts | $_________________________ | $_________________________ |
| Real Estate | $_________________________ | $_________________________ |
| Motor Vehicles | $_________________________ | $_________________________ |
| Other Personal Property | $_________________________ | $_________________________ |
| TOTAL ASSETS | $____________ + $____________ = ____________/B | |
| EXCEPTIONAL EXPENSES (total exceptions expenses of dependents) | ||
| Medical Expenses | $_________________________ | |
| Court-ordered support payments/alimony | $_________________________ | |
| Child-care payments (e.g. day care) | $_________________________ | |
| Other (describe) _______________________ | $_________________________ | |
| TOTAL EXCEPTIONAL EXPENSES | $_________________________ | |
| =_______________________/C | ||
STATE OF NEW MEXICO
COUNTY OF OTERO
CITY OF ALAMOGORDO
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 and the court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies.
________________________ ________________________________________
Date Signature of applicant
State of New Mexico )
County of _________________ ) ss
City of ___________________ )
Signed and sworn to (or affirmed) before me on ________________________ (date) by ________________________________________________________ (name of applicant).
______________________________
Notary
(Seal, if any) My commission expires: _______________________
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 OF THIS DECISION.
____ I wish to appeal.
____ I do not wish to appeal.
SCREENING USE ONLY
COLUMN "A" (net income)
plus COLUMN "B" (assets)
minus COLUMN "C" (exceptional expenses) AVAILABLE FUNDS
equals AVAILABLE FUNDS .......... = /_________
INDIGENCY TABLE:
Household size (self & dependents*)
1 2 3 4 5 6 7 8
Available
Funds (annually) $10,830 $14,570 $18,310 $22,050 $25,790 $29,530 $33,270 $37,010
Add $3,480.00 for each additional dependent* member
____ The applicant is indigent.
____ The applicant is not indigent.
____ The applicant (has) (has not) paid the $10.00 application fee.
________________________________ ________________________________
Signature of screening agent Title
*(Dependent means any person who qualifies as a dependent of the applicant under Section 152 of the Internal Revenue Code.)
Based on the above answers and information, I find that the applicant (is) (is not) indigent.
(Complete the following only if the court has determined that the applicant is unable to pay the $10.00 application fee).
____ I find that the applicant is unable to pay the $10.00 indigency application fee, and I therefore waive the payment of the $10.00 application fee.
________________________________________________
Judge or authorized designee
APPROVED_______________________________
DISAPPROVED ___________________________
REASON:____________________________________________________________________________________________________________