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DISTRICT COURT, STATE OF UTAH 

COUNTY of                                                     

   

AFFIDAVIT and 
APPLICATION FOR A COURT- APPOINTED LAWYER   

I swear that the following is true: Due to my poverty I am unable to bear the expense of hiring an 

deductions 
$ 

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deductions 
$ 

  

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 was born on 

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uvenile Court only: I am applying for my child whose name is 

  I have a job. My employer’s name and address is: 

onthly    pay before 

onthly pay after 

    

  

My address is 

My telephone number is 

 

attorney. 
 

 

My name is 

  I don’t have a job. The last time I worked was on _______________, _______.    My 

employer’s name and address was: 

y wages at that job were $_____________ per _______________. 

  Last year my total income from all sources was (You must answer this question or your 

application will be rejected.) 

  I receive this much alimony per    month 

  I receive this much child support per month 

  I receive this much per month from government programs such as social security benefits, 

AFDC, food stamps, worker’s compensation, veterans non-educational benefits, housing, food, 
or other living allowances paid to members of the military, clergy, and others. 

  I have this much money in cash, in the bank or other available source 

  Other people owe me this much money 

 

 

 

       

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Affidavit and Application for a Court-Appointed Lawyer, Page 2– 

  I own or am buying a home, land or other real property and vehicles or other personal property as listed 

below. 

roperty (home, land, vehicles, etc.) 

ocation 

Value 

 

 

 

 

 

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ater/Sewer 

elephone 

ar Payments 

edical 
Payments 

as 

  

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  In an average month I spend money for the following items. 

Amount 

Amount 

ther (list) 

Amount 

  

 

 

 

 

 

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ood 

lothing 

ransportation 

ortgage/rent 

lectricity 

  

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  The last date that I sold, traded or gave away any property was                                                                                              . 

  I owe the following debts. 

To whom owed 

Amount 

To whom owed 

Amount 

 

  

  

  

  

  

  

  

  

  

  

Name 

Age 

Relationship 

Name 

Age 

Relationship 

  The following people depend on me for support. 

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                                                                                                                                      (Do not write below this line) 
 

                                                                                                                                                                                                                                             

 

igned on                                                                      , 20                                 

                                                                                           

                                                                   
(Signature of Applicant) 

  

  

  

  

  

  

  

  

  

  

Affidavit and Application for a Court-Appointed Lawyer, Page 3– 

 state under criminal penalty of the State of Utah that the foregoing is true and correct. 

Prosecutor’s Certificate 

I have read the above affidavit. The public defender     should  should not be appointed. 

 The Court should reserve jurisdiction to allow the county to claim reimbursement. 

Other comments: 

                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                                     
                                                                                                                                                                       

igned on                                                                        , 20                             

                                                                                           

                                                                   
(Signature of Prosecutor) 

  

  

  

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tate of Utah, 

in the case of 

_____________________________, 

Defendant or Juvenile. 

 
ORDER ON AFFIDAVIT and 
APPLICATION FOR A COURT- APPOINTED 
LAWYER   
 
Case No. ____________________ 
 

 
THE COURT HEREBY incorporates the facts set out in the Affidavit, with any modifications 

indicated verbally on the court record or written below; and FINDS and ORDERS as follows: 

 

 

 
Family size is 

 

 

 

 

 

 

Income is   

150% of Poverty Guideline is   

 

 Defendant is not indigent. 
 

 Lawrence H. Hunt  Mandy Larsen  William Leigh  Douglas L. Neeley  Michael 
 Mathie  Dale Sessions  JoHanna Williams   
 Other (specify):                                                                                                                                is appointed.   

he defendant could be ordered to reimburse the County for their lawyer.   

Signed on _______________, 20_____ 

_________________________________________ 

JUDGE 

Notice to Public Defender 

 In Court on the record 

 Mailing 

 Hand delivery 

 Facsimile transmission 

igned on _______________, 20_____ 

                                                                                                         

Affidavit and Application for a Court-Appointed Lawyer, Page 4– 

SIXTH DISTRICT COURTS, STATE OF UTAH 
COUNTY of _____________________________ 

  

 

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