Affidavit of Indigence

In the Utah County Justice Court

Utah County, State of Utah

First Name:

Please enter your first name.

Middle Name:

Last Name:

This field is required.

Address:

This field is required.

Apartment #:

City:

This field is required.

State:

This field is required.

Zip:

This field is required.

DOB:

This field is required.

Phone #:

This field is required.

Email:

This field is required.

STATE OF UTAH Plaintiff vs.

This field is required.

Case No.

This field is required.

Defendant provides the following information required by Utah Code Section 77-32-202;

Procedure for determination of indigency - Standards.

A determination of indigency or continuing indigency of any defendant may be made by the court at any stage of the proceedings.
1. "Indigency" means that a person:
  1. does not have sufficient income, assets, credit, or other means to provide for the payment of legal counsel and all other necessary expenses of representation without depriving that person or the family of that person of food, shelter, clothing and other necessities; or
  2. has an income level at or below 150% of the United States poverty level as defined by the most recently revised poverty income guidelines published by the United States Department of Health and Human Services; and
  3. has not transferred or otherwise disposed of any assets since the commission of the offense with the intent of establishing eligibility for the appointment of counsel under this chapter.
2. In making a determination of indigency, the court shall consider:
  1. the probable expense and burden of defending the case;
  2. the ownership of, or any interest in, any tangible or intangible personal property or real property, or reasonable expectancy of any such interest;
  3. the amounts of debt owned by the defendant or that might reasonably be incurred by the defendant because of illness or other needs within the defendant's family;
  4. number, ages, and relationships of any dependents; and
  5. other relevant factors.
1. If the trial court finds within one year after the determination of indigency that any defendant was erroneously or improperly determined to be indigent, the county or municipality may proceed against that defendant for the reasonable value of the services rendered to the defendant, including all costs paid by the county or municipality in providing the defense counsel.
2. A defendant claiming indigency has a continuing duty to inform the court of any material changes or change in circumstances that may affect the deterination of his eligibility for indigency.
3. Any person who intentionally or knowingly makes a material false statement or omits a material fact in an affidavit for indigency is guilty of a class B misdemeanor.
Orem City v. Bergstrom, 1999 UT App 350, 992 P. 2d 991. In Bergstrom, specifically, the court stated that "determining whether a defendant is indigent is a fact-intensive inquiry, requiring a consideration of the defendant's entire financial situation." The court should consider defendant's "employment status and earning capacity; financial aid from family or friends; financial assistance from state or federal programs; the defendant's necessary living expenses and liabilitis; his unencumbered assets, or any disposition thereof, and borrowing capacity."

77-32-302. Assignment of counsel on request of indigence or order of court.

Legal counsel shall be assigned to represent each indigent and the indigent shall also be provided access to defense resources necessary for an effective defense, if the indigent is under arrest for or charged with a crime in which there is a substantial probability that the penalty to be imposed is confinement in either jail or prison.

DEFENDANT'S FINANCIAL INFORMATION:

Fill out the following completely and truthfully.

Current employer(s):

Employer Name:

Address:

City:

State:

Zip:

Monthly Gross Income:

Hourly Wage:

Hours Worked Weekly:

Monthly Alimony Received:

Monthly Child Support Received:

Income in the past 12 months from any other non-governmental source including business, profession or other self-employment; rent payments; interest or dividends; pensions, annuities, or life insurance payments; gifts or inheritance:

Income from government financial support including social security benefits, AFDC, worker's compensation, veterans non-educational benefits, housing, food, or other living allowances paid to members of military, clergy, and others:

Are you currently unemployed?

Yes

If you answered yes to the above question, list the date when last employed:

Last Employer's Name:

Last Employer's Address:

City:

State:

Zip:

Monthly Salary/Wages of last employment:

Why are you unemployed?

Amount in cash or in any bank accounts including savings and checking:

This field is required.

Outstanding accounts that are owed to you, that have not been collected:

This field is required.

ASSETS:

List of home, land or other real property and vehicles or other personal property owned in whole or part by Defendant, its location and its approximate value. Include any real or personal property which Defendant has transferred to a third party since the date of the offense alleged in the information.

Property:

Location:

Value:

List of Defendant's debts:

Owed To:

Amount:

List of Defendant's monthly expenses:

Expense Type:

Amount:

Defendant's Dependants:

Record the names of Spouse, Children, etc., that you financially support.

Name:

Age:

Relationship:

Being sworn, I state that I,

This field is required.

, am the Defendant; that I have read this affidavit and the statements in it are true and correct to the best of my knowledge; and that due to my poverty I am unable to bear the expense of hiring an attorney to defend myself in this proceeding.

Electronic Signature Agreement: By typing your signature, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Defendant Signature:

This field is required.