IN THE CIRCUIT COURT OF GARLAND COUNTY, ARKANSAS

JUVENILE DIVISION
ARKANSAS DEPARTMENT OF
HUMAN SERVICES
VS.

PLAINTIFF
CASE NO. JV-20XX-XXX

MOTHERXXX, MOTHER
FATHERXXX, FATHER OF:
SONXXX, (DOB: xx/xx/xx), MALE
DAUGHTER1XXX, (DOB: xx/xx/xx), FEMALE
DAUGHTER2XXX, (DOB: xx/xx/xx), FEMALE
MINOR CHILDREN

DEFENDANTS

MOTION FOR INDIGENCY DETERMINATION OR IN THE

ALTERNATIVE FOR HEARING
Comes now, MOTHERXXX, by and through her attorney, _______________________,
and for her Motion for Indigency Determination, states and alleges as follows:
1. That, jurisdiction and venue with this Court are proper.
2. That, by Order of this Court, MOTHERXXXs parental rights have been terminated
with respect to the minor child stated within the caption of this case.
3. That, movant wishes to appeal said Order terminating her parental rights.
4. That, movant is indigent, as evidenced by her Affidavit of Indigency, filed herein and
attached to this Motion as Exhibit A,
5. That, movant requests the court enter an Order of Indigency, or in the alternative, set
a hearing to determine her indigency for purposes of appeal.
Wherefore, Defendant, MOTHERXXX, prays that this Court enter an Order of
Indigency, or in the alternative to conduct a hearing on her Affidavit of Indigency; that she be

found indigent for purposes of appeal; and, for any and all other relief deemed just and proper by
this honorable Court.

Respectfully submitted,
MOTHERXXX
By: ____________________________
____________________________
Attorney for Defendant Mother
Address
Phone
Fax
E-mail
CERTIFICATE OF SERVICE
I, __________________________, certify that I have served a true and correct
copy of the foregoing pleading on the attorneys of record for all parties in the case via fax at the
fax numbers listed below, on this day, ________________________, 20___.
____________________________