I,__________________________, Defendant, swear under penalty of perjury that the following information
is true and complete. 

ALL ITEMS MUST BE FULLY COMPLETED.  PRINT NEATLY

Defendant’s Name:____________________________           Marital status: Single Married

Address:____________________________________           Divorced Separated Widowed

Home telephone #:____________________________            Number in Household:___________

Cellphone #:_________________________________           List Names and Ages:____________

Social Security #:_____________________________            Driver’s License #:______________   

Most recent employer:__________________________________________________________

Address:_________________________________________Telephone #:__________________

Dates Employed:________________Hours/Week:______________Pay rate:_______________

Pay dates:______________________Position: _________________Length of employment____

OWN_____________ RENT_____________

House(s) or other property:  Est. Value:_______________ Loan balance:___________________

Year purchased:___________County and address:____________________________________

Vehicles:  Year: ______ Model: _____________________Value:_____________

Cash on hand:________________Credit cards: (Type and balance owed):___________________

Bank Accounts:

Type:____________________________Bank Name:___________________________________

Account #:_____________________________________Balance:_________________________

Stocks, bonds, other investments:

Type:____________________________Name:_______________________________________

Account #:____________________________________Balance:_________________________

TOTAL ASSETS: _____________________CONVERTIBLE TO CASH:_________________     

Gross Monthly Income:_____________________       Monthly Expenses:___________________

Earnings (Self):___________________________       Rent/Mortgage:______________________

Earnings (Spouse):________________________        Food:______________________________

Other responsible parties: __________________         Utilities:____________________________

Unemployment Benefits:___________________          Clothing:___________________________

Social security:___________________________        Alimony/Child Support: _______________

Alimony/Child Support:____________________         Medical:____________________________

Food Stamps/Public Assistance:______________        Credit/Loans: _______________________

Other Income (identify source):______________         Other Expenses (Identify):______________

TOTAL Income:__________________________       TOTAL Expenses:____________________

I swear under penalty of perjury that all information provided is true and complete. In addition, I authorize the Court to make any necessary contacts to verify the information.  I also understand that if the court grants this request, I may later be ordered to reimburse the City & County of Broomfield for attorney fees spent on my behalf.

Defendant’s Signature:_________________________________________Date:______________

ORDER

The Court has reviewed the Application for Court Appointed Counsel and the Defendant’s request is (granted) or (denied).

                                                                        Date:__________________________By the Court:

____________________________________

Presiding Municipal Court Judge