___________________COURT

[Precinct _____]

____________County, Arizona

STATE OF ARIZONA Plaintiff

[CASE/COMPLAINT NO.]

-vs-

MOTION FOR

APPOINTMENT

OF COUNSEL

Defendant (FIRST, MI, LAST)

MOTION FOR APPOINTMENT OF COUNSEL

Defendant moves for the appointment of Counsel and declares that Defendant’s financial circumstances will not allow the hiring of a private attorney in this case.

Signature ________________

Date _________________

Phone No. _______________

Address ________________________________________

_______________________________________

ORDER

[ ]

Motion for Court Appointed Counsel is granted.

(Check if applicable)

[ ] A financial assessment is ordered for a recommendation to the Court as to defendant’s eligibility and any contribution amount to the cost of the court appointed attorney.

[ ] $ __________ for financial assessment.

[ ] $ __________ for contribution to the cost of the court appointed attorney.

[ ] Legal Services to be provided by ________________________________

Phone No. ___________________________________

[ ]

Motion for court appointed attorney is denied.

Judicial Officer ____________________

Date _____________________

Courtroom ___________