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OFFICE USE ONLY:

Public Defender: ____________

Conflict Defender: ____________

Assigned Counsel: ____________

Other: _____________________________________

Application for Attorney Services (Criminal Court)

ST. LAWRENCE COUNTY INDIGENT DEFENSE

Please print clearly and answer all required questions on this application

48 Court Street, Canton, N.Y. 13617

INCOMPLETE APPLICATIONS WILL DELAY A DECISION.

Phone: (315) 379-2401 / Fax: (315) 379-0401

NOTE: This application will be reviewed by individuals who are not your attorney. DO NOT write or include any information that may be important to your case.

INFORMATION ABOUT YOU:

Name:

Former Name: ______________________________________

Gender: MALE / FEMALE

Mailing Address: _________________________ Physical Address: _________________________ City: ________________ State: ______ Zip Code: ________

Home Phone: ________________ Other Phone: ________________ Message Phone: ________________

E-mail:__________________________________

D.O.B.:

Age: _ _ Where were you born? ___________________________

Have you been a member of the Armed Forces?

YES / NO

Last Four of Social Security: XXXX-XX-______

Marital Status: SINGLE / MARRIED

Spouse’s Name: _____________________________________

INFORMATION ABOUT CRIMINAL CHARGES:

Court where charges are pending: ______________________________ Judge: _________________

Next court date:

Time:

_____

Charges:

______

_________________________________ _

Date of arrest:

Are you in jail:

YES / NO

Date put in jail:

Have you been released on bail:

YES / NO

Was anyone charged with you:

YES / NO

If yes, list name(s): ___________________________________________________________________________

Alleged Victim’s Name:

____________ _____ Other Parties: ______ ___________________

____

Are you applying for a Violation of Probation Hearing?

YES / NO

What was the conviction that resulted in a probation sentence? ______________________

Have you tried to hire an attorney for the charges listed above?

YES / NO

Who: _____________________________________________________________

Do you presently have other pending charges?

YES / NO

If yes, list the court and charges: _____________________________________________________

__________________________________________________________________________________________________________________________________

Are you currently being represented by an attorney on these other charges?

YES / NO

WHO: ___________________________________________________

If you answered yes, was the attorney: ( ) Retained

( ) Assigned

( ) Assigned with repayment

Monthly payment: _____________

Application For Attorney Services (Criminal Court) Form - St. Lawrence County Indigent Defense

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