IN THE ________DISTRICT JUVENILE COURT

IN AND FOR __________ COUNTY, STATE OF UTAH

STATE OF UTAH, in the interest of

A person under eighteen years of age.	MOTION OR REQUEST FOR

APPOINTMENT OF COUNSEL

Case No. ___________

I, ______________________________________ , the child, parent, guardian, or

custodian of the above named child(ren), hereby request this Court to appoint an attorney to

represent

_______ said child(ren)

_______ me (the parent, guardian, custodian or child)

in all matters pending before this Court. I am indigent or without sufficient funds to pay

for costs of counsel.

I have attached an Affidavit in Support of Motion or Request for Appointment of Counsel

for the Court's consideration.

This request is made pursuant to U.C.A. 78-3a-913.

Dated this _______ day of _______________________, 20___.

__________________________________

Parent(s), Guardian, Custodian, Child

IN THE ________DISTRICT JUVENILE COURT

IN AND FOR COUNTY, STATE OF UTAH

STATE OF UTAH, in the interest of

A person under eighteen years of age.	AFFIDAVIT IN SUPPORT OF

MOTION OR REQUEST FOR

APPOINTMENT OF COUNSEL

Case No. ________________
I, the parents(s) of _________________________, hereby state under oath, as follows:

1. I reside at _________________________________________________.

2. I am single ( ) Separated ( ) Married ( ) Divorced ( )

3. The household presently supports the following members:

Number of children under 18 ( ) Yourself ( ) Spouse ( )

Name(s) and age(s) of child(ren)___________________________________________

4. I am ( ) employed ( ) not employed and have a net pay per month of $ ________

5. My spouse is ( ) is not ( ) employed and his/her net pay per month is $________

6. Other members of the household are employed and bring in net pay per month of

$______________.

7. I have the following or additional sources of income per month:

(a) public assistance	$____________

(b) Social Security	$____________

(c) Veteran's benefits	$____________

(d) retirement	$____________

(e) unemployment compensation	$____________

(f) child support	$____________

(g) savings	$____________

(h) rental property	$____________

(i) stocks / bonds (value)	$____________

(j) Trust fund / inheritance	$____________

(k) other (list)	$____________

8. My expenses are:

food	$____________

clothing	$____________

transportation (gas, bus)	$____________

mortgage/rent	$____________

Utilities:

electricity	$____________

gas	$____________

water / sewer	$____________

Car payment:	$___________

Credit Cards:	$___________

Visa	$____________

Master Charge	$____________

Other:	$___________

Medical payments:	$___________

Other debts (list)	$___________

Total	$___________

I, the affiant, herewith state that the above information is true and correct and understand that wilful misrepresentation may be subject to penalty for perjury under the law.

Subscribed this ________ day of _____________________, 20____.

_____________________________

Affiant's signature