In the matter of 

First and last name(s), alias(es)

1. I, 

Name

  on 

Date

  Hon. 

 , declare my intent to appeal from the order entered

 in the 
 

 Court by

 .

 

2. I understand I have the right to be represented by an attorney. I am unable to pay fully for the services of an attorney and
 

for the cost of transcripts and have completed the Financial Schedule on page 2 of this form.

3. I request an attorney be appointed by the court and the cost of transcripts be waived. I understand I may be ordered to
 

reimburse the court for all or part of the attorney fees and transcript costs.

4. I authorize the court to investigate and obtain any further relevant information from my employer, creditors, the Michigan 
  Department of Health and Human Services, the Social Security Administration, and others who have knowledge of my 
financial circumstances for purposes of aiding the court in determining my eligibility for the appointment of an attorney 
 
  and waiver of costs of transcripts.

Date

Signature

 

Address

 

 

Name (please print)

City, state, zip                                                                            Telephone no.

Approved, SCAO
Form JC 81, Rev. 3/21
MCR 3.993
Page 1 of 2

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYREQUEST FORCOURT APPOINTED APPELLATE COUNSELCASE NO.PETITION NO.JUDGECourt addressCourt telephone no.JIS Code: RFCRequest for Court Appointed Appellate Counsel 
Page 2 of 2

(3/21) 

Case No. 
 

Complete this Financial Schedule if you are seeking a court-appointed attorney.

FINANCIAL SCHEDULE

 Own          

 Live with parents         

   

 Room/Board     

1. RESIDENCE
             

 Rent            

2. MARITAL STATUS

             

 Single           

 Married       

 Divorced                                 Separated                         

 Dependents: 

Number

3. INCOME       a. Employer name and address

b. Length of employment

d. Other income 

  State monthly amount and source, such as MDHHS, VA, rent, pensions, spouse, unemployment, child support, etc.

 weekly                      

 monthly            

 every two weeks

c. Average of pay
  

Gross: $ 
 

 Net: $ 
 

4. ASSETS 

  State value of car, home, bank deposits, bonds, stocks, etc.

5. OBLIGATIONS 

 

Itemize monthly rent, installment payments, mortgage payments, child support, etc.

6. REIMBURSEMENT 

 

I understand that I may be ordered to reimburse the court for all or part of my attorney and defense costs.

I declare under the penalties of perjury that the above information has been examined by me and that its contents are true 
to the best of my information, knowledge, and belief.

Date

 

Signature