Form 358jv - Application For Public Defender Services Form - Juvenile Page 2
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1
2Other Employed Household Members
Employer’s Address
Name of Household Member
Name of Employer
Change in Monthly Income:
If your current monthly income is significantly different from last year’s income,
please describe your current monthly income and the reasons why it changed.
My income last year (past 12 months) was
$
The income from other household members last year was
$
The reason for the change is
: (This section must be filled out if you have a change in income.)
I request the Court assign a lawyer to represent
me
the juvenile in this case because of my low income. I further ask
that all necessary costs and expenses for legal services, as allowed by the court, be paid by the State of Vermont.
I make the above answers UNDER PENALTY OF PERJURY.
Signed and sworn before me:
Notary Public
Date
Date
Applicant Signature
DETERMINATION OF FINANCIAL ELIGIBILITY
Applicant is not a financially needy person in that applicant has sufficient income to retain
private counsel and/or has sufficient liquid or non-liquid assets which could provide collateral to
borrow funds to retain private counsel.
Applicant is a financially needy person in that applicant does not have sufficient income to
retain private counsel and does not have sufficient liquid or non-liquid assets which could provide
collateral to borrow funds to retain private counsel.
Minimum Payment: Applicant’s household income is under 125% of poverty. Applicant is ORDERED to pay
the minimum payment of $50 within 60 days unless this fee is waived by the Court.
Immediate Copayment: Applicant’s annual household income is above 125% of poverty and applicant has
income and assets available to support an immediate copayment to cover a part of the cost of services
to the clerk of the court
Applicant shall pay
$
Reimbursement Order: Applicant’s annual household income is above 125% of poverty and applicant has
income and assets available to reimburse the state for the cost of services.
to the clerk of the court within 60 day of the date of
Applicant shall pay
$
this Order
NOTICE
: If reimbursement is not fully paid within 60 days, any amount still due will be sent to the Tax
Department for offset and collection.
Signature of Clerk or Designee
Date
FINDINGS AND ORDER
The court has reviewed the Petition and Affidavit, and finds that:
The interests of justice require representation of the Juvenile.
The interests of justice require representation of the Applicant.
The interests of justice do NOT require representation of the Applicant.
It is hereby ORDERED:
COUNSEL ASSIGNED to Juvenile
COUNSEL ASSIGNED to Applicant in that applicant is financially needy and the interests
of justice so require
COUNSEL DENIED to APPLICANT.
Date
Signature of Judge
NOTICE OF RIGHT TO APPEAL: You have the right to appeal this order to the judge of this
court. Your appeal must be filed in writing with the clerk of this court within 7 days of the date
of this order.
Form 358JV PD Juvenile Application (05/2016)
Page 2 of 2
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