Application for Legal Assistance

IN THE JUVENILE COURT OF TANEY COUNTY, MISSOURI
IN THE INTEREST OF: ______________________________________________ DOB: ___________

CASE NUMBER: _____________________________________ A child/children under 18 years of age

You have the right to have an attorney represent you in the case listed above. If you cannot afford an attorney, you
may complete this form to determine if you qualify to have an attorney appointed for you. All questions must be
answered (leave no blanks) and applications may be denied if incomplete.

Return the application to the Taney County Juvenile Office at 266 Main Street, Forsyth MO 65653 or via mail to P O
Box 482, Forsyth MO 65653.

APPLICATION FOR LEGAL ASSISTANCE
(PLEASE PRINT ANSWERS TO ALL INFORMATION REQUESTED BELOW)

NAME______________________________________________PHONE___________________SSN#_______________________

ADDRESS________________________________________________________________________________________________

EMAIL ADDRESS_______________________________________________ DOB__________SEX______

MARITAL STATUS___________COUNTY OF RESIDENCE____________________________________

EMPLOYER______________________________________GROSS MONTHLY SALARY$________________________________

SPOUSE’S NAME_________________________________________ # OF CHILDREN AT HOME TODAY _________________

SPOUSE’S EMPLOYER______________________________________________ GROSS MONTHLY SALARY$______________

DO YOU OR ANYONE IN YOUR HOUSEHOLD RECEIVE: AFDC $__________ VA $___________ SSI $_______________

SS DISABILITY $___________________ RETIREMENT $_______________________ OTHER INCOME $___________________

NO. OF VEHICLES________ VALUE OF VEHICLES $_______________ OWED ON VEHICLES $________________________

DO YOU OWN: HOUSE _____ VALUE $_______________ AMOUNT OWED ON HOUSE $___________

LAND _______ VALUE $_______________ AMOUNT OWED ON LAND $___________

MOBILE HOME ________ VALUE $_______________ AMOUNT OWED ON HOME $___________

BANK ACCOUNT INFORMATION: CHECKING ACCT BALANCE $_________________________

SAVINGS ACCT BALANCE $_________________________

CD’S/STOCKS/OTHER $_________________________

REASON FOR REQUESTING LEGAL COUNSEL (WHAT DO YOU WANT AN ATTORNEY TO DO FOR YOU—USE BACK OF
FORM IF NECESSARY)

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IN THE INTEREST OF: ______________________________________________ DOB: ___________

CASE NUMBER: _____________________________________ A child/children under 18 years of age

I STATE THAT ALL THE INFORMATION PROVIDED BY ME ON THIS APPLICATION IS TRUE AND
CORRECT.

I UNDERSTAND AND AGREE THAT: (1) LEGAL COUNSEL MAY BE DENIED OR TERMINATED IF I
PROVIDE FALSE INFORMATION ON THIS APPLICATION AND THAT THE COSTS FOR ANY LEGAL
SERVICES PROVIDED MAY BE ASSESSED AGAINST ME; (2) I MUST NOTIFY BOTH THE JUVENILE
COURT AND MY ATTORNEY OF ANY CHANGE IN ADDRESS, TELPHONE NUMBER, OR FINANCIAL
STATUS WITHIN 4 DAYS OF THE CHANGE; (3) THE APPOINTMENT OF LEGAL COUNSEL APPLIES
ONLY TO THE MATTER PENDING AT THIS TIME; AND (4) I MUST REAPPLY FOR NEW COUNSEL IN
THE EVENT THAT A PETITION TO TERMINATE PARENTAL RIGHTS IS FILED OR IF AN APPEAL IS
FILED.

I FURTHER UNDERSTAND AND AGREE THAT MY LEGAL COUNSEL WILL BE DISCHARGED AND I
WILL NEED TO PERSONALLY APPEAR IN COURT TO REQUEST THAT NEW COUNSEL BE
APPOINTED IF, ABSENT GOOD CAUSE SHOWN: (1) I FAIL TO ATTEND ANY COURT HEARING; (2) I
FAIL TO ATTEND ANY FAMILY SUPPORT TEAM MEETING; (3) I FAIL TO STAY IN CONTACT WITH
MY ATTORNEY; (4) I FAIL TO NOTIFY BOTH THE JUVENILE COURT AND MY ATTORNEY OF ANY
CHANGE IN ADDRESS OR TELEPHONE NUMBER WITHIN 4 DAYS OF CHANGING MY ADDRESS OR
TELEPHONE NUMBER; OR (5) I FAIL TO NOTIFY THE JUVENILE COURT AND MY ATTORNEY OF
ANY CHANGE IN MY FINANCIAL STATUS WITHIN 4 DAYS OF THE CHANGE IN STATUS.

DATE____________________ SIGNATURE_______________________________________________

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