AFFIDAVIT OF INDIGENCE Sample Clauses

AFFIDAVIT OF INDIGENCE. In the Municipal Court of the City of Biloxi, Mississippi CITY OF BILOXI
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AFFIDAVIT OF INDIGENCE. The Affidavit of Indigence, which is attached as Exhibit A (Form Three) to the Agreement, is hereby replaced by the form labeled Affidavit of Indigence, which is attached hereto as Exhibit 1 (Form Four).
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AFFIDAVIT OF INDIGENCE. To determine eligibility for Court Appointed Attorney, YOU MUST COMPLETE THIS FORM: Size of family unit :Members of immediate family that you support financially, name & relationship Name:__________________________ Age:___________________ Relationship:____________________________ ___________________________ ___________________ ____________________________ ___________________________ ___________________ ____________________________ ___________________________ ___________________ ____________________________ Monthly Income: Your Salary:_________________ Rent/Mortgage: _____________________ Spouse Salary: ______________ Transportation/Vehice: Make and Model: ________________________ Car Payment: _____________________ Car Insurance: _____________ SSI/SSDI: ____________________ SS Check:___________________ Utilities: ___________________ Child Support: _____________________ Clothes/Food: ________________ Day Care:____________________ Health Ins.________________________ Credit Cards:__________________ Medical Expenses: ___________________ Other Income:____________________________________________________________________________________ Staff Use ONLY: Total Montly income: __________ Total Monthly Expenses: _______ Defendant Meets Eligibility Requirements: Difference:Net Income:_________ ____ YES ____NO _____UNDETERMINED I have been advised of my right to representation by counsel in the trial of the charge pending against me. I certify that I am without means to employ counsel of my own choosing and I hereby request the court to appoint counsel for me. I swear that the above information is true and correct. The information I listed is accurate and I will immediately notify the court of any changes in my financial situation. ****All information is subject to verification. Falsification of information is a criminal offense**** ___________________________________ ____________________________________
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Related to AFFIDAVIT OF INDIGENCE

  • AFFIDAVIT The undersigned swear or affirm that the foregoing statements are correct and include all material information necessary to identify and explain the terms and operation of our joint venture and the intended participation by each joint venturer in the undertaking. Further, the undersigned covenant and agree to provide to the County current, complete and accurate information regarding actual joint venture work and the payment therefore and any proposed changes in any of the joint venture. Also, permit authorized representatives of the County to audit and examine records of the joint venture. Any material misrepresentation will be grounds for terminating any contract which may be awarded and for initiating action under Federal or State laws concerning false statements." Name of Firm: Name of Firm: Signature: Signature: Name: Name: Title: Title: Date: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY – PAGE 4 Date State of County of AFFIDAVIT STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐ physical presence, or ☐ online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐ Personally Known; OR ☐ Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) ORANGE COUNTY, FLORIDA Procurement Division CONTRACT NO. Y22-1022 SHUTTLE BUS SERVICES FOR OCCC This contract is not valid unless bilaterally executed. Subject to mutual agreement Orange County, Florida, hereby enters into a contract subject to the following:

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  • Certificate of Insurance/Endorsements A certificate of insurance from an insurer with a Best's rating of no less than A- indicating compliance with the required coverages has been received by the Department’s Contracts Management Bureau, X.X. Xxx 000000, Xxxxxx, XX 00000. Contractor must notify the Department immediately of any material change in insurance coverage, such as changes in limits, coverages, change in status of policy, etc. The Department reserves the right to require complete copies of insurance policies at all times.

  • Certification of Coverage Engineer shall furnish County with a certification of coverage issued by the insurer. Engineer shall not cause any insurance to be canceled nor permit any insurance to lapse. In addition to any other notification requires set forth hereunder, Engineer shall also notify County, within twenty-four (24) hours of receipt, of any notices of expiration, cancellation, non-renewal, or material change in coverage it receives from its insurer.

  • Certificate of Insurance Contractor must provide a Certificate of Insurance form to the City of Sparks to evidence the insurance policies and coverage required of Contractor.

  • Opinion of Counsel for Company At Closing Time, the Representative shall have received the favorable opinion, dated as of Closing Time, of Xxxxxx, Xxxxx & Xxxxxxx LLP, counsel for the Company, in form and substance satisfactory to counsel for the Underwriters, together with signed or reproduced copies of such letter for each of the other Underwriters to the effect set forth in Exhibit A hereto and to such further effect as counsel to the Underwriters may reasonably request.

  • Contractor’s Certification (1) By entering into this contract, the Contractor (and officials thereof) certifies that neither it nor any person or firm who has a substantial interest in the Contractor's firm is a person or firm ineligible to be awarded Government contracts by virtue of the sanctions imposed under 41 U.S.C. 6706.

  • FIRPTA Seller is not a foreign corporation, foreign partnership, foreign trust or foreign estate (as those items are defined in the Internal Revenue Code and Income Tax Regulations).

  • Content of Contractor's certification As required in paragraph (l)(5) of this clause, the Contractor shall make the following certification in each request for performance-based payment: I certify to the best of my knowledge and belief that --

  • Contractor’s Certifications A. Contractor certifies that it has not engaged in corrupt, fraudulent, collusive, or coercive practices in competing for or in executing the Contract. For the purposes of this Paragraph 10.05:

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