APPENDIX C — CAPTION AND CERTIFICATION FORMS

Section C-14. Request for appointed counsel

Cite asRid. R. Sup. Ct. app. C-14Official text at page 51

REQUEST FOR APPOINTED COUNSEL
1. Proceeding, charge, judgment, or custody at issue: [________]
2. Current counsel: [________ / NONE]
3. Efforts to obtain counsel: [________]
4. Statutory basis for eligibility: [________]
5. Known conflict with State Public Defender: [________ / NONE]
6. Immediate deadline or hearing: [________]
No confidential financial detail is included in this public form.
[Identify any secure supporting submission.]
/s/ [REQUESTING PARTY]