Public Defender Application Form - Elk County
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2OTN No. ________________________
APPLICATION FOR ASSIGNMENT OF LEGAL COUNSEL
If you are unable to hire an attorney because of lack of sufficient funds and are charged with a crime, juvenile delinquency, appealing
a criminal conviction, involved in habeas corpus, extradition, parole or probation proceedings, you may qualify to have an attorney
provided for you at no cost.
PLEASE FILL IN EVERY SECTION FULLY AND COMPLETELY
************************************************
I hereby make application for an attorney from the Public Defender Of ________________County and represent as follows:
1. Name _______________________________________________________________________________ Age ________________
Present Address: __________________________________ City_____________________State______ Zip____________
Phone _______________________ Social Security No. ****-***-__________ (last 4 digits only)
2. Person usually knowing your whereabouts:
Name _______________________________________________________________________ Relationship ________________
Address:__________________________________________City_____________________State_______Zip___________
Phone ______________________
3. I am involved in the following proceedings: (check one)
( ) Criminal Charges
( ) Probation/Parole Violation
( ) Other (Describe Below)
4. List the specific Criminal Charges: ____________________________________________________________________________
_________________________________________________________________________________________________________
Preliminary Hearing Date _______________________________________________________________ Time _______________
Location ___________________________________________________ Police Dept. __________________________
Date of Incident(s) ____________________ Arresting Officer ______________________________________________________
Are you in Jail __________Date of Arrest __________________ What date were you incarcerated? ________________________
Bail Amount _________________________________ How was Bail made? __________________________________________
5. Do you have prior criminal convictions? ______________If Yes, complete the following:
Date
Charges
Sentence
_______________
_________________________________
____________________________________________
_______________
_________________________________
____________________________________________
_______________
_________________________________
____________________________________________
6. Personal Information:
(a) Marital Status: ( ) Single
( ) Married
( ) Divorced
( ) Separated
( ) Other
(b) Number of Dependents, names and ages: ____________________________________________________________________
_________________________________________________________________________________________________________
(c) Are you currently supporting them ______________ Monthly Amount ____________________________________________
7. My present financial status is:
(a) Assets (Value of what you own)
VALUE
Cash, checking and savings accounts
$___________________________________
Bank _________________________________________________
Real Estate______________________________________________
$___________________________________
Car(s): Make(s) and Year(s)________________________________
_______________________________________________________
$___________________________________
Money owed to you
$___________________________________
List three most valuable items owned
_______________________________________________________
$___________________________________
_______________________________________________________
$___________________________________
_______________________________________________________
$___________________________________
TOTAL ASSETS
$___________________________________
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