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IN THE JUSTICE COURT, IN AND FOR
CITY*
1. ALPINE CITY
2. HIGHLAND CITY
UTAH COUNTY, STATE OF UTAH. 5400 W Civic Center Dr. Ste 4, Highland, UT 84003
CITY, Plaintiff,*
1. CITY OF ALPINE
2. CITY OF HIGHLAND
APPLICATION FOR APPOINTMENT OF COUNSEL AND AFFIDAVIT OF FINANCIAL CONDITION.
VS*
Case Number:*
Defendant.
I, *
, on oath depose and state that I am accused of the crime of *
and request the Court to appoint counsel to represent me at public expense. The following affidavit is submitted of application:
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Give make, year value, amount owing thereon, if any and to whom the vehicles is registered or titled. Also give lien holder information, if any.*
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List all sources of income, including salary, wages, pensions, bonds, stocks, securities, private business, farming, insurance, retirement benefits, or other:*
Value *
ADC, Welfare or other State assistance $ (Monthly)*
Real estate owned, other than homestead*
Value $*
Are you a beneficiary or heir in any estate of a person deceased?
Do you receive unemployment compensation?*
1. Yes
2. No
3. N/A
If so give the monthly amount? $
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Does anyone owe you any money at all for the services you have rendered, or do you have title to any property which you claim to have interest as owner or otherwise? Give details in full:*
I do solemnly swear or affirm that due to my poverty I am unable to bear the expense of the action or legal proceedings which I am about to commence and that I believe I am entitled to relief sought by the action or legal proceeding.
Being sworn, I state that I am the Defendant and that I have read this Affidavit and the statements in it are true and correct to the best of my knowledge.
Electronic Signature Authorization*
1. By checking this box and typing my name below, I am electronically signing this form.
First Name*
Last Name*
Date*
Date

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