Form 358jv - Application For Public Defender Services Form - Juvenile
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1
2APPLICATION FOR PUBLIC DEFENDER SERVICES - Juvenile
Division
Unit
Case Type
Docket Number
State of Vermont
Vermont Superior Court
FAMILY
First
Last
Name of Juvenile
Name
Street Address
Others Living with You (include adults and children)
Town/City
State
Zip
Telephone Number
Date of Birth
Social Security Number
Total Number in Household
(including Yourself)
EMPLOYMENT
Employer(s) Name(s) and Address(es) :
Are you employed?
Yes
No
If Yes, fill in employer’s name(s) and address(es)
INCOME
EXPENSES
Yes
No
If all adults living with you receive public assistance, it
is not necessary to fill out the Expenses section below.
Do you receive Public Assistance?
(
including TANF/Reach UP; SSI, General Assistance)
Otherwise, enter your monthly household expenses
Do Any Family Members Living With You
Receive Public Assistance
Current Monthly Income
Rent or Mortgage Pmt.
$________________
Other
Household
You
Electric Service
Members Living
With You
$________________
Gross Income from Wages
Phone
$____________
$___________
$________________
Self Employment/Business Income
Fuel (heat and/or gas)
(other than wages)
$____________
$___________
$________________
Food
Unemployment Compensation
$____________
$___________
$________________
Child Support
Clothing
$____________
$___________
$________________
Public Assistance
Medical
$____________
$___________
$________________
Other Income
(Including Disability
Child Support
Insurance and Social Security)
$____________
$___________
$________________
$
$
Total Income
Auto Loan Payments
$________________
Total Monthly Income
$
Property Taxes
(Your income plus Household members)
$________________
Total Income in the past 12
$
Insurance(Incl. Health, Auto, etc)
months
$________________
Is your income in the last 30 days significantly different
Yes
No
Other Expenses
from your monthly income during the previous year
$________________
If YES, please explain the circumstances on the next page.
Total Expenses
$
Cash Assets
Other Assets
Real Estate (Location)
Auto (Make , Model, Yr)
Cash On Hand
$__________
_________________
_____
______________________
Fair Market
Checking Account
$__________
$_____________
$_______________
Value
Outstanding
Savings Account
$__________
$_____________
$_______________
Mortgage/Loan
Total Cash Assets
$__________
$_____________
$_______________
Net Value
NOTICE: You may be ordered to pay a minimum fee towards the cost of your legal services even if you are
receiving public assistance. You may ask the court to reduce the amount you are ordered to pay.
Additional Assets:
I have additional assets: Yes
No
If Yes, describe them below
Vehicles
Make, Model, Year
Fair Market
Amount Owed
Net value
Value (FMV)
$
$
$
$
$
$
$
$
$
$
$
$
Real Property
Description
FMV
Mortgage
Net Value
$
$
$
$
$
$
Other Assets
Description
FMV
Use additional sheets as necessary.
e.g. tools,
equipment, recreational vehicles,
$
electronics, stocks, bonds, etc.
$
Form 358JV PD Juvenile Application (05/2016)
Page 1 of 2
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Parent category: Business