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`THE CIRCUIT COURT OF LOGAN COUNTY, ARKANSA|
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`[72]
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`SOUTHERN DIVISION
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`STATE OF ARKANSAS PLAINTIFF
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`V. CASE NO. 42BCR-25-73
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`JOHN GOFF DEFENDANT
`AFFIDAVIT OF INDIGENCY
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`O NN (\fé\i’)’gi\‘ , the defendant in the above-captioned proceeding, being first duly sworn
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`on oath, deposes and states:
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`A. PUBLIC DEFENDER INFORMATION
`| have been evaluated by the office of the state public defender: ( ) Yes (l/fi\lo
`If yes, | have been found: }?7) Eligible ( )Ineligible ( ) Partially Eligible
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`B. PERSONAL INFORMATION P
`Date of Birth \ \ l \q C/\D
`Martial Status: K/)"Single ( )Married ( )Separated ( ) Divorced
`Children and Ages: \\ '\~ C | . ,
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`Do these children live in the home? ( )Yes (¥)No
`Do any other persons live in your home? ( )Yes ( 0
`If yes, explain: \\ W\
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`Mobile Phone: Email:
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`C. EMPLOYMENT INFORMATION
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`Current Employer: X% @\/\ C_
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`Address and Telephone of Employer: A\ AYaN =
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`Supervisor:N\0 O\ '\f\o Net or take home pay: $ AN Q V\‘() per"\‘r\\ Q f/\\ I
`If married and not separated:
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`Spouse’s Employer: v\ <O WWESH
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`Address and Telephone of E‘mployer‘:\f\ Q) b il £
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`Supervisor: \O\ N\ C " Net or take home pay$_{\ QN perin 2 AN
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`D. ASSETS (include assets of spouse if married and not separated)
`‘ Stocks: S
`Checking:) $ Other
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`E. NON-LIQUID ASSETS (Equity=value-money owed)(Include assets of spouse if married and not separated)
`Real Estate (house):
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`Vehicles (car, truck, cycle): $_\ /X _\
`Other: s\ \ ) \[\ Q//‘
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`F. LIABILITIES (Money owed, including that of your spouse if married and not separated)
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`SOURCE REASON TOTAL AMOUNT MONTHLY PAYMENT
`1o [\ 7 N )
`2\ N\ L 3 N ¥ i
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`G. AVERAGE MONTHLY Bl/JDGET
`House (raft, mortgage): S
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`Food: /& Utilities: __
`. Hea \/ehicle Insurance:
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`Child Support:
`Recurring Prescription Drugs:
`Court Proceeding:
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`Day Care:
`Recurring;/\edica ?
`I
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`wn v vnn
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`Education
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`H. FAILED ATTEMPTS TO SECURE LEGAL COUNSEL
`(List names and addresses of attorney whom you have consulted)
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`AN AWRVANYS
`A N O T g
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`\
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`I, swear that the above statements are true and correct to the best of my knowledge and recollection;
`that |, have not sold or disposed of any assets for less than their fair market value prior to the
`commencement of the above-captioned proceeding in order to obtain appointed counsel; and that |
`understand that furnishing false information under oath may subject me to a criminal prosecution,
`with a possible punishment of up to 6 years in the Arkansas Department of Corrections and a fine
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`of up to $10,000. Further, | state that any change in my financial condition will be reported to both
`this Court and appointed counsel immediately.
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`SNe C SR
`In exchange for legal representation provided by the State, |, NN S NN N/\, >0 ,
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`Agree to pay the amount ordered by the Court, both upon the initial Appointment of an Attorney (user
`Fee) and for any amount ordered by the Court after the case has concluded (attorney fee).
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`Your state income tax refund, legal settlements of favorable verdicts, lottery winnings, or any moneys
`or property forfeited by the State shall be intercepted to satisfy this debt under Ark. Code
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`Ann. 16-87-217.
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`(Dgnda nt
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`Subscribed and sworn to before me this day of ,20
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`State of Arkansas Notary Public
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`My commission ires:
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`JUDGE DATE
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`PAGE 2 OF 2
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