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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:____________________________________________________________________________________________________________