Form NHJB-2955-P "Request for State of New Hampshire to Pay Court-Appointed Counsel" - New Hampshire

What Is Form NHJB-2955-P?

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

Form Details:

  • Released on June 26, 2018;
  • The latest edition provided by the New Hampshire Judicial Branch;
  • 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 NHJB-2955-P by clicking the link below or browse more documents and templates provided by the New Hampshire Judicial Branch.

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Download Form NHJB-2955-P "Request for State of New Hampshire to Pay Court-Appointed Counsel" - New Hampshire

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Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
REQUEST FOR STATE OF NEW HAMPSHIRE TO PAY
COURT-APPOINTED COUNSEL
Guardianship of Incapacitated Person (RSA 464-A)
(Information pertains to proposed ward)
1. Name of person completing form if different than proposed ward:
2. Proposed ward name:
Date of birth:
Telephone:
3. Legal residence of proposed ward:
Street
City/Town
State
Zip Code
4. Mailing address
:
(If different from above)
P. O. Box/Street
City/Town
State
Zip Code
5. Marital status
:
Single
Married
Divorced
Separated
Widowed
(Check one)
6. Name of spouse:
7. Address of spouse:
8. Living arrangement
:
Alone
w/Spouse
w/Parent(s)
(Check one)
w/Children
w/Friend(s)
Other:
FINANCIAL INFORMATION - ASSETS and LIABILITIES
(Information pertains to proposed ward)
9. List the names, ages, and relationship of dependents that proposed ward supports:
Name
Age
Relationship
10. If proposed ward is presently employed, state where and for how long:
Name of employer:
How long employed here:
Full-Time
Part-Time
11. If unemployed, state last date of employment:
12. If proposed ward’s spouse is presently employed, state where and for how long:
Name of employer:
How long employed here:
Full-Time
Part-Time
13. If proposed ward’s spouse is unemployed, state last date of employment:
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NHJB-2955-P (06/26/2018)
Page 1 of 4
Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
REQUEST FOR STATE OF NEW HAMPSHIRE TO PAY
COURT-APPOINTED COUNSEL
Guardianship of Incapacitated Person (RSA 464-A)
(Information pertains to proposed ward)
1. Name of person completing form if different than proposed ward:
2. Proposed ward name:
Date of birth:
Telephone:
3. Legal residence of proposed ward:
Street
City/Town
State
Zip Code
4. Mailing address
:
(If different from above)
P. O. Box/Street
City/Town
State
Zip Code
5. Marital status
:
Single
Married
Divorced
Separated
Widowed
(Check one)
6. Name of spouse:
7. Address of spouse:
8. Living arrangement
:
Alone
w/Spouse
w/Parent(s)
(Check one)
w/Children
w/Friend(s)
Other:
FINANCIAL INFORMATION - ASSETS and LIABILITIES
(Information pertains to proposed ward)
9. List the names, ages, and relationship of dependents that proposed ward supports:
Name
Age
Relationship
10. If proposed ward is presently employed, state where and for how long:
Name of employer:
How long employed here:
Full-Time
Part-Time
11. If unemployed, state last date of employment:
12. If proposed ward’s spouse is presently employed, state where and for how long:
Name of employer:
How long employed here:
Full-Time
Part-Time
13. If proposed ward’s spouse is unemployed, state last date of employment:
Top of Page
NHJB-2955-P (06/26/2018)
Page 1 of 4
Case Name:
Case Number:
REQUEST FOR STATE OF NH TO PAY COURT-APPOINTED COUNSEL
14. List all other household members, their monthly income and their contributions to the household
expenses if any.
Name
Monthly Income
Monthly Contribution
$
$
$
$
15. List any real estate that proposed ward owns, its market value and the amount owed. If jointly
owned, value would be half of total market value and mortgage owed.
Location:
Market Value
$
Mortgage Owed
$
Net Value of Real Estate (Market Value minus Mortgage Owed)
$
0.00
16. List any vehicles proposed ward owns (car, truck, motorcycle, snowmobile, recreation vehicle),
their market value and the amount owed:
Description
Market Value
Amount
Net Value
(Market Value
Owed
minus Amt Owed)
$
$
$
0.00
$
$
$
0.00
$
$
$
0.00
17. What money is presently available to proposed ward?
Cash on hand ..................................................................................... $
Checking account ............................................................................... $
Savings account ................................................................................. $
Stocks/Bonds/IRA/Pension ................................................................. $
Total
$
0.00
18. Please state monthly take-home amount
Proposed ward Spouse
(A)
(B)
Alimony
$
$
Child Support
$
$
Investment income
$
$
Unemployment Compensation
$
$
Salary/Wages
$
$
Social Security*
$
$
Pension/Trust Benefits
$
$
Welfare Payments*
$
$
Other (if not listed above)
$
$
Total
$
$
0.00
0.00
* This income is not considered when determining eligibility for payment of court appointed counsel
NHJB-2955-P (06/26/2018)
Page 2 of 4
Top of 1st Page
Case Name:
Case Number:
REQUEST FOR STATE OF NH TO PAY COURT-APPOINTED COUNSEL
19. Please state the proposed ward’s monthly household expenses:
Rent/Mortgage $
Property Taxes $
Heat
$
Food
$
Utilities
$
Medical/Dental $
Insurance
$
Other
$
Please specify
Total
$
0.00
20. List income tax paid last year:
Federal $
State $
21. List income tax refund received last year: Federal $
State $
22. Other than monthly household expenses, list any bills that the proposed ward owes, amount
owed, to whom, and monthly payment:
23. List which of the bills are court-ordered payments (i.e. alimony, judgment in a law suit, etc.):
24. Other than those previously mentioned, list anyone to whom proposed ward owes money,
amount and when it is due:
25. If anyone owes the proposed ward money, state name, address, amount due, and when due:
26. List any property the proposed ward has transferred within the last three years, to whom and for
what price:
27. List any other assets, income or expenses not previously mentioned:
Top of 1st Page
NHJB-2955-P (06/26/2018)
Page 3 of 4
Case Name:
Case Number:
REQUEST FOR STATE OF NH TO PAY COURT-APPOINTED COUNSEL
I understand that the proposed ward may be required to repay the State of New Hampshire for the
services provided by court-appointed counsel unless the court finds that the proposed ward is or will
be financially unable to pay. I understand that if at any time prior to the final disposition of the case,
the proposed ward’s financial condition improves, I must notify the court immediately. By submitting
this Request and Financial Information, I acknowledge that the proposed ward’s financial condition
may be investigated, employment and credit verified, and a report made to the court.
I swear or affirm the foregoing information is true and correct to the best of my knowledge under
penalties of law.
I certify that on this date I provided this document(s) to the parties who have filed an appearance for
this case or who are otherwise interested parties by:
Hand-delivery OR
US Mail OR
Email
.
(E-mail only by prior agreement of the parties based on Circuit Court Administrative Order)
Date
Signature of Person completing form
(must be signed in the presence of a Notarial Officer)
Date
Signature of Person completing form
(must be signed in the presence of a Notarial Officer)
State of
, County of
This instrument was acknowledged before me on
by
Date
Person Completing Form
My Commission Expires
Affix Seal, if any
Signature of Notarial Officer / Title
ORDER
Based on this Request and the Financial Information of Assets and Liabilities, the proposed ward is:
Ineligible to have the State of NH pay for court appointed counsel fees and expenses.
Eligible to have the State of NH pay for court appointed counsel fees and expenses.
Eligible to have the State of NH pay for court appointed counsel fees and expenses, but liable
for partial or full repayment to the State of NH. The amount due will be determined once the
Statement of Services has been filed by the Attorney for the ward and approved by the court.
An Order for Repayment will be issued at that time.
Date
Signature of Judge
Printed Name of Judge
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NHJB-2955-P (06/26/2018)
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