On April 23, 2013 a
Request,Application
was filed
in the District Court of Payne County.
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IN THE DISTRICT COURT OF PAYNE COUNTY, STATE OF OKLAHOMA 's
Plaintiff ‘NH s212*
vs. Case Number = 013 = t67
Defendant g
APPLICATION FOR APPOINTED COUNSEL ij
AND
AFFIDAVIT OF FINANCIAL INABILITY TO EMPLOY COUNSEL
| swear and affirm that | am the party in the above entitled action. | want an attorney to represent
me in this case. | am financially unable to obtain the services of an attorney without causing
substantial hardship to myself or to my family. The following information is true and is given and
intended to be relied upon by the court and other persons or agencies in determining my eligibility
for legal services to be furnished to me at public expense.
PLEASE FILL IN ALL SPACES BELOW AND SIGN YOUR NAME UNDER OATH IN FRONT OF
THE JUDGE, A NOTARY OR THE COURT CLERK. IF A QUESTION DOES NOT APPLY TO
YOU, PLEASE WRITE IN THE BLANK “DOES NOT APPLY”.
I. GENERAL INFORMATION Date: /0 —=23- /3
NAME: gen Toe ba
ADDRESS: dy je 6 9% Shilo ten ote 24074
TELEPHONE: (ys) 7 93. 2 y3
MESSAGE NUMBER: SOCIAL SECURITY NUMBER: _{y?~ 22~ Cor /
AGE: 2) DATE OF BIRTH: /-2/~ 96
SINGLE:(=] MARRIED: [ ] SEPARATED: [ ]
SPOUSE’S NAME:
ADDRESS:
TELEPHONE:
HOW MANY PEOPLE ARE IN YOUR HOUSEHOLD?
:
NAMES AND AGES: (14.4 Baepes?” skate, baby whet, f.-s
NOTES, MORTGAGES AND TRUST DEEDS: __-6—
ANY DEBTS OWED TO THE DEFENDANT: -e-
OTHER ASSETS AND PROPERTY: VALUE: ~O-
ARE YOU PARTY TO A SUIT (PROBATE, WORKER'S COMPENSATION, PERSONAL
INJURY) WHERE JUDGMENT MAY BE EXPECTED?: YES[ ]NO[ 4
NAME OF ATTORNEY?:
MM. EXPENSES AND DEBTS
RENT/HOUSE PAYMENT: Oo CLOTHING: _-> FOOD: _©
DOCTOR/MEDICINE: - UTILITIES: a
CAR PAYMENT: > INSURANCE: =
OTHER: =
TOTAL MONTHLY LIVING EXPENSES: 2
MORTGAGEE/LANDLORD'S NAME: oe
MAJOR DEBTS: (list to whom and amount owed):
LIST THE PERSONS WHO ARE DEPENDENT ON YOU FOR SUPPORT. STATE YOUR
RELATIONSHIP TO EACH PERSON AND HOW MUCH YOU CONTRIBUTE TO THEIR
SUPPORT: FE &
Vv. LAST EMPLOYMENT:
WHEN DID YOU LAST WORK?: 0
WHO WAS YOUR EMPLOYER?:
SALARY: 2 HOW LONG DID YOU WORK THERE? __o-
WHY DID YOU QUIT?Mi. THE FOLLOWING PEOPLE CAN VERIFY TO A LARGE EXTENT MY ABOVE
MENTIONED FINANCIAL SITUATION, GIVE NAME, ADDRESS AND PHONE NUMBER.
1.
2.
3.
VIL. CHARGE AND BOND
CHARGE(S): FELONY: _ &~ MISDEMEANOR: JUVENILE:
ARRESTING AGENCY:
CITY: 54, 4 wn f COUNTY: _ [2 yne STATE: ___o%
HAS BOND BEEN POSTED? YES[ ]NO[~] DID YOU USE A BONDSMAN? YES [{ ] NO[ ]
WHO PAID THE BONDSMAN?
AMOUNT OF BOND? . PREMIUM PAID TO BONDING CO:
IF YOU DID NOT USE A BONDSMAN, DID YOU POST
CASH BOND: PR BOND
LIST ANY DEFENDANT'S CHARGED WITH YOU:
VIL.
4 Have you transferred or sold any assets since charges were filed in this case?
YES[ ]NO[)Ifso, describe the buyer and the amount received.
2. Have you retained counsel in this case or in any other pending criminal case?
YES[{ JNO (Ait so, state the case number, court, attorney and amount paid for
services:
3. Do you have any friends or relatives who are able and willing to assist you in hiring
Counsel and paying for transcripts? YES [ ] NO [~J If so, have those persons been
asked to help? YES[ ]NO[ ]
4. If a friend or relative has given previous financial assistance in this case, but is no longer
able or willing to do so, an affidavit to that effect from that person should be attached. Is
that affidavit attached? YES[ ]NO[~]
vill. | NAMES OF THREE ATTORNEYS YOU CONTACTED:
1. NAME
WHEN DID YOU CONTACT THIS ATTORNEY?
HOW DID YOU CONTACT THIS ATTORNEY?
CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ ]NO[7_
2. NAME
WHEN DID YOU CONTACT THIS ATTORNEY?
HOW DID YOU CONTACT THIS ATTORNEY?
CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ ]NOET
3. NAME
‘WHEN DID YOU CONTACT THIS ATTORNEY?
HOW DID YOU CONTACT THIS ATTORNEY?
CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ JNOL-Tx.
| DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION | HAVE
PROVIDED IS TRUE AND CORRECT. | UNDERSTAND THAT I MAY BE PROSECUTED FOR
PROVIDING FALSE INFORMATION IN THIS APPLICATION AND AFFIDAVIT. | UNDERSTAND
THAT | MUST INFORM THE OKLAHOMA INDIGENT DEFENSE SYSTEM OF ANY CHANGE IN
MY FINANCIAL SITUATION THAT MAY CHANGE THE INFORMATION | HAVE PROVIDED. |
FURTHER DECLARE THAT | HAVE CONTACTED THREE ATTORNEYS, LICENSED TO
PRACTICE LAW IN THIS STATE, AND ! AM WITHOUT FUNDS TO PAY AN ATTORNEY TO
REPRESENT ME OR TO PAY FOR TRANSCRIPTS AND COSTS ASSOCIATED WITH THIS
CASE.
Oc Phen
DATED AND SIGNED THIS ses? DAY OF 23 vf 20 £3
DEFENDANT. tela Deo Zoe hry
LEGAL GUARDIAN |,
Don &
SUBSCRIBED AND SWORN TO BEFORE ME ON THR _" DAY OF : 20 .
MY COMMISSION EXPIRES , 20
NOTARY (oP CLERK or JUDGE)
APPLICATION FEE WAIVER
| FIND THAT THE DEFENDANT IS UNABLE TO PAY THE APPLICATION FEE AND |
HEREBY WAIVE THE FEE.
JUDGE
NOTICE
A copy of this APPLICATION AND AFFIDAVIT shall be sent to the prosecuting attorney
or office of attorney general, whichever is applicable, for review and, upon request, the court shall
hold a hearing to determine your eligibility for legal services to be furnished to you at public
expense.
IMPORTANT NOTICE
The court shall order you to pay the costs of your legal representation in total, or in
installments. The court shall set the amount and due date of each installment payment. The
costs shall be paid to the court clerk in your county. The costs shall be a debt against you until
paid and shall subject you to debt collection procedures as provided by law. The costs shall be
deducted from any state income tax refund due you until the total costs are paid.
Document Filed Date
October 24, 2013
Case Filing Date
April 23, 2013
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IN THE DISTRICT COURT OF PAYNE COUNTY, STATE OF OKLAHOMA 's Plaintiff ‘NH s212* vs. Case Number = 013 = t67 Defendant g APPLICATION FOR APPOINTED COUNSEL ij AND AFFIDAVIT OF FINANCIAL INABILITY TO EMPLOY COUNSEL | swear and affirm that | am the party in the above entitled action. | want an attorney to represent me in this case. | am financially unable to obtain the services of an attorney without causing substantial hardship to myself or to my family. The following information is true and is given and intended to be relied upon by the court and other persons or agencies in determining my eligibility for legal services to be furnished to me at public expense. PLEASE FILL IN ALL SPACES BELOW AND SIGN YOUR NAME UNDER OATH IN FRONT OF THE JUDGE, A NOTARY OR THE COURT CLERK. IF A QUESTION DOES NOT APPLY TO YOU, PLEASE WRITE IN THE BLANK “DOES NOT APPLY”. I. GENERAL INFORMATION Date: /0 —=23- /3 NAME: gen Toe ba ADDRESS: dy je 6 9% Shilo ten ote 24074 TELEPHONE: (ys) 7 93. 2 y3 MESSAGE NUMBER: SOCIAL SECURITY NUMBER: _{y?~ 22~ Cor / AGE: 2) DATE OF BIRTH: /-2/~ 96 SINGLE:(=] MARRIED: [ ] SEPARATED: [ ] SPOUSE’S NAME: ADDRESS: TELEPHONE: HOW MANY PEOPLE ARE IN YOUR HOUSEHOLD? : NAMES AND AGES: (14.4 Baepes?” skate, baby whet, f.-s NOTES, MORTGAGES AND TRUST DEEDS: __-6— ANY DEBTS OWED TO THE DEFENDANT: -e- OTHER ASSETS AND PROPERTY: VALUE: ~O- ARE YOU PARTY TO A SUIT (PROBATE, WORKER'S COMPENSATION, PERSONAL INJURY) WHERE JUDGMENT MAY BE EXPECTED?: YES[ ]NO[ 4 NAME OF ATTORNEY?: MM. EXPENSES AND DEBTS RENT/HOUSE PAYMENT: Oo CLOTHING: _-> FOOD: _© DOCTOR/MEDICINE: - UTILITIES: a CAR PAYMENT: > INSURANCE: = OTHER: = TOTAL MONTHLY LIVING EXPENSES: 2 MORTGAGEE/LANDLORD'S NAME: oe MAJOR DEBTS: (list to whom and amount owed): LIST THE PERSONS WHO ARE DEPENDENT ON YOU FOR SUPPORT. STATE YOUR RELATIONSHIP TO EACH PERSON AND HOW MUCH YOU CONTRIBUTE TO THEIR SUPPORT: FE & Vv. LAST EMPLOYMENT: WHEN DID YOU LAST WORK?: 0 WHO WAS YOUR EMPLOYER?: SALARY: 2 HOW LONG DID YOU WORK THERE? __o- WHY DID YOU QUIT?Mi. THE FOLLOWING PEOPLE CAN VERIFY TO A LARGE EXTENT MY ABOVE MENTIONED FINANCIAL SITUATION, GIVE NAME, ADDRESS AND PHONE NUMBER. 1. 2. 3. VIL. CHARGE AND BOND CHARGE(S): FELONY: _ &~ MISDEMEANOR: JUVENILE: ARRESTING AGENCY: CITY: 54, 4 wn f COUNTY: _ [2 yne STATE: ___o% HAS BOND BEEN POSTED? YES[ ]NO[~] DID YOU USE A BONDSMAN? YES [{ ] NO[ ] WHO PAID THE BONDSMAN? AMOUNT OF BOND? . PREMIUM PAID TO BONDING CO: IF YOU DID NOT USE A BONDSMAN, DID YOU POST CASH BOND: PR BOND LIST ANY DEFENDANT'S CHARGED WITH YOU: VIL. 4 Have you transferred or sold any assets since charges were filed in this case? YES[ ]NO[)Ifso, describe the buyer and the amount received. 2. Have you retained counsel in this case or in any other pending criminal case? YES[{ JNO (Ait so, state the case number, court, attorney and amount paid for services: 3. Do you have any friends or relatives who are able and willing to assist you in hiring Counsel and paying for transcripts? YES [ ] NO [~J If so, have those persons been asked to help? YES[ ]NO[ ] 4. If a friend or relative has given previous financial assistance in this case, but is no longer able or willing to do so, an affidavit to that effect from that person should be attached. Is that affidavit attached? YES[ ]NO[~] vill. | NAMES OF THREE ATTORNEYS YOU CONTACTED: 1. NAME WHEN DID YOU CONTACT THIS ATTORNEY? HOW DID YOU CONTACT THIS ATTORNEY? CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ ]NO[7_ 2. NAME WHEN DID YOU CONTACT THIS ATTORNEY? HOW DID YOU CONTACT THIS ATTORNEY? CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ ]NOET 3. NAME ‘WHEN DID YOU CONTACT THIS ATTORNEY? HOW DID YOU CONTACT THIS ATTORNEY? CAN YOU AFFORD TO HIRE THIS ATTORNEY? YES[ JNOL-Tx. | DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION | HAVE PROVIDED IS TRUE AND CORRECT. | UNDERSTAND THAT I MAY BE PROSECUTED FOR PROVIDING FALSE INFORMATION IN THIS APPLICATION AND AFFIDAVIT. | UNDERSTAND THAT | MUST INFORM THE OKLAHOMA INDIGENT DEFENSE SYSTEM OF ANY CHANGE IN MY FINANCIAL SITUATION THAT MAY CHANGE THE INFORMATION | HAVE PROVIDED. | FURTHER DECLARE THAT | HAVE CONTACTED THREE ATTORNEYS, LICENSED TO PRACTICE LAW IN THIS STATE, AND ! AM WITHOUT FUNDS TO PAY AN ATTORNEY TO REPRESENT ME OR TO PAY FOR TRANSCRIPTS AND COSTS ASSOCIATED WITH THIS CASE. Oc Phen DATED AND SIGNED THIS ses? DAY OF 23 vf 20 £3 DEFENDANT. tela Deo Zoe hry LEGAL GUARDIAN |, Don & SUBSCRIBED AND SWORN TO BEFORE ME ON THR _" DAY OF : 20 . MY COMMISSION EXPIRES , 20 NOTARY (oP CLERK or JUDGE) APPLICATION FEE WAIVER | FIND THAT THE DEFENDANT IS UNABLE TO PAY THE APPLICATION FEE AND | HEREBY WAIVE THE FEE. JUDGE NOTICE A copy of this APPLICATION AND AFFIDAVIT shall be sent to the prosecuting attorney or office of attorney general, whichever is applicable, for review and, upon request, the court shall hold a hearing to determine your eligibility for legal services to be furnished to you at public expense. IMPORTANT NOTICE The court shall order you to pay the costs of your legal representation in total, or in installments. The court shall set the amount and due date of each installment payment. The costs shall be paid to the court clerk in your county. The costs shall be a debt against you until paid and shall subject you to debt collection procedures as provided by law. The costs shall be deducted from any state income tax refund due you until the total costs are paid.