Section 1 of 1 in this document

City of Orem Justice Court

Affidavit of Indigency

First Name

Last Name

Phone Number

If you are pleading NOT GUILTY and asking for a court-appointed attorney to represent you, you must answer these questions under oath.

You are signing at the bottom under the penalties of perjury. Any false statements will place you in contempt of court and subject you to criminal liability.

What kind of work do you do?

How many family members do you support?

Do you help support anyone outside the United States?

Yes

How often do you work?

How much do you get paid per hour?

How much money have you earned so far this year?

How much money did you earn last year & report on your taxes?

How many hours do you work on average per week?

How much do you get paid per hour?

How much money have you earned so far this year?

How much money did you earn last year & report on your taxes?

Being unemployed, how do you support yourself?

How long have you been unemployed?

What job/earning skills do you have?

Do you live with parents, family or friends?

Yes

What is the relationship to those you live with?

Do you pay rent or expenses to them?

Yes

How much do you pay per month?

What other sources of income do you have that you have not disclosed above?

Do you own a car?

Yes

What is the year, make and model of the car(s) you own?

What other assets do you own (home, property, savings, etc)?

How much do you pay each month in a cell phone bill?

Describe any extraordinary expenses you may have

I swear and affirm under penalties of contempt and perjury that the financial information given above is complete, accurate and truthful.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

City of Orem Justice Court

Affidavit of Indigency

Full Address

Do you help support anyone outside the United States?

Do you live with parents, family or friends?

Do you pay rent or expenses to them?

Do you own a car?

Date Picker

Sign Here