Form AOC-DNA-11 "Financial Statement, Affidavit of Indigence, Request for Counsel and Order (Dna/Tpr/Adoption Cases)" - Kentucky

What Is Form AOC-DNA-11?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Kentucky Court of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-DNA-11 by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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Download Form AOC-DNA-11 "Financial Statement, Affidavit of Indigence, Request for Counsel and Order (Dna/Tpr/Adoption Cases)" - Kentucky

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AOC-DNA-11
Doc. Code: AICO
Case No. _____________________
Rev. 7-18
Page 1 of 2
l e x
e t
j u s t i t i a
Court
q District
q Family
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
County ______________________
Financial Statement, Affidavit of Indigence,
KRS Chapter 31; KRS 199.502
Request for Counsel and Order
KRS 620.100; 625.0405; 625.060;
Division ______________________
625.080; FCRPP 17
(DNA/TPR/ADOPTION Cases)
IN THE INTEREST OF: _________________________________________________________________, A CHILD
I AM A (check one):
q parent who exercises custodial control or supervision of the above-named child in a dependency, neglect or abuse action;
q person (not a parent) who exercises custodial control or supervision of the above-named child in a dependency, neglect
or abuse action;
q person (not a parent) claiming to be a de facto custodian of the above-named child in a dependency, neglect or abuse
action;
q parent of the above-named child in a termination of parental rights action; or
q biological parent of the above-named child who does not consent in an adoption action.
AND HEREBY PROVIDE THE FOLLOWING INFORMATION:
NAME: __________________________________________________________________________________
ADDRESS: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
SSN: _____________________________ DOB: ______________________ Telephone: ______________________
(mm/dd/yyyy)
Area code + number
q The above-named parent is an unemancipated minor (under the age of 18) and I am his/her parent or legal
guardian _______________________________________________________.
(Name of Parent or Legal Guardian of Minor Parent)
FINANCIAL STATEMENT: (Complete the following information. NOTE: If the child’s parent is an unemancipated
minor, the adult parent or legal guardian of the unemancipated minor should provide the information)
1. Are you employed? q Yes q No
2. If “Yes,” are you q Full time; q Part time; or q Seasonal/Temporary
3. How many adults are living in your household? ____
4. How many children are living in your household? _____
5. Total Household Income Per Month:
$_________________
6. Available Cash from ALL SOURCES (bank accts, TANF, SSI, SSD, W/C, etc.)
$_________________
7. Cash value of other resources (food stamps, WIC, etc.)
$_________________
9. Property Ownership: q Yes q No
Property Value:
$_________________
10. Number of autos you own that are in working order: ______ Total Value:
$_________________
11. Total Value of All Other Assets:
$_________________
12. Total Debts:
$_________________
13. Child support obligation? q Yes q No
Monthly Total:
$_________________
14. Other obligations _______________________________________________________________________
15. Number of dependents: ____________
REQUEST FOR THE APPOINTMENT OF LEGAL COUNSEL:
I state to the court that:
(1) I am not now represented by legal counsel; and
(2) I am without sufficient monetary means or assets to afford private legal representation.
AOC-DNA-11
Doc. Code: AICO
Case No. _____________________
Rev. 7-18
Page 1 of 2
l e x
e t
j u s t i t i a
Court
q District
q Family
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
County ______________________
Financial Statement, Affidavit of Indigence,
KRS Chapter 31; KRS 199.502
Request for Counsel and Order
KRS 620.100; 625.0405; 625.060;
Division ______________________
625.080; FCRPP 17
(DNA/TPR/ADOPTION Cases)
IN THE INTEREST OF: _________________________________________________________________, A CHILD
I AM A (check one):
q parent who exercises custodial control or supervision of the above-named child in a dependency, neglect or abuse action;
q person (not a parent) who exercises custodial control or supervision of the above-named child in a dependency, neglect
or abuse action;
q person (not a parent) claiming to be a de facto custodian of the above-named child in a dependency, neglect or abuse
action;
q parent of the above-named child in a termination of parental rights action; or
q biological parent of the above-named child who does not consent in an adoption action.
AND HEREBY PROVIDE THE FOLLOWING INFORMATION:
NAME: __________________________________________________________________________________
ADDRESS: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
SSN: _____________________________ DOB: ______________________ Telephone: ______________________
(mm/dd/yyyy)
Area code + number
q The above-named parent is an unemancipated minor (under the age of 18) and I am his/her parent or legal
guardian _______________________________________________________.
(Name of Parent or Legal Guardian of Minor Parent)
FINANCIAL STATEMENT: (Complete the following information. NOTE: If the child’s parent is an unemancipated
minor, the adult parent or legal guardian of the unemancipated minor should provide the information)
1. Are you employed? q Yes q No
2. If “Yes,” are you q Full time; q Part time; or q Seasonal/Temporary
3. How many adults are living in your household? ____
4. How many children are living in your household? _____
5. Total Household Income Per Month:
$_________________
6. Available Cash from ALL SOURCES (bank accts, TANF, SSI, SSD, W/C, etc.)
$_________________
7. Cash value of other resources (food stamps, WIC, etc.)
$_________________
9. Property Ownership: q Yes q No
Property Value:
$_________________
10. Number of autos you own that are in working order: ______ Total Value:
$_________________
11. Total Value of All Other Assets:
$_________________
12. Total Debts:
$_________________
13. Child support obligation? q Yes q No
Monthly Total:
$_________________
14. Other obligations _______________________________________________________________________
15. Number of dependents: ____________
REQUEST FOR THE APPOINTMENT OF LEGAL COUNSEL:
I state to the court that:
(1) I am not now represented by legal counsel; and
(2) I am without sufficient monetary means or assets to afford private legal representation.
AOC-DNA-11
Rev. 7-18
Case No. ___________________________
Page 2 of 2
AFFIDAVIT OF INDIGENCE
PERJURY WARNING
I understand that making a false statement in the Financial Statement, Affidavit of Indigence and Request for
Appointment of Counsel may subject me to the penalties for perjury as contained in KRS Chapter 523. The maximum
sentence for perjury is five (5) years imprisonment. I declare under the penalty of perjury that I have read or have had
read to me the information contained on this form and that the statements provided here are true, complete and accurate
to the best of my personal knowledge.
____________________________________
____________________________________________
Date
Affiant’s Signature
_____________________________________
Affiant’s Name (print or type)
SUBSCRIBED AND SWORN TO before me this ________ day of __________________________, 2________.
My Commission Expires: _________________________
____________________________________________
Attesting Officer or Notary’s Signature
ORDER
Based on this application/motion, IT IS HEREBY ORDERED:
1. The applicant, or legal guardian/parent of the applicant:
q is NOT deemed indigent under KRS Chapter 31.
q IS found to be indigent under KRS Chapter 31.
2. APPOINTMENT OF COUNSEL
q is DENIED.
q is GRANTED.
The Court, having determined that the applicant is a needy person as defined in KRS 31.110 and that, pursuant to KRS
Chapter 620, further proceedings regarding the above-named child are required, or that the applicant is a party to a
termination of parental rights or an adoption proceeding, DOES HEREBY APPOINT the Hon. ________________________
to represent the applicant. Counsel’s fee, fixed by the Court at the appropriate statutory amount, shall be paid by the
Finance and Administration Cabinet pursuant to KRS 620.100, 625.080, or 199.502.
____________________________________
____________________________________________
Date
Judge’s Signature
____________________________________________
Judge’s Name (print or type)
Distribution:
q Court File
q Applicant
q Appointed Counsel
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