Application For Attorney Services (Criminal Court) Form - St. Lawrence County Indigent Defense Page 3
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4LIST ALL HOUSEHOLD MEMBERS AND THEIR INCOME (including dependents). *Provide pay stubs for the last 30 days, W-2, or a recent tax return transcript.
Name
Relationship
Employed
Gross Pay
Weekly,
Receiving
to Applicant
Age
Yes or No
Bi-Weekly,
Public Benefits
List ALL household members, including children.
You MUST provide proof of income.
Monthly
Yes or No
SELF
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DO YOU OR ANYONE IN YOUR HOUSEHOLD RECEIVE ANY OF THE FOLLOWING (please indicate weekly, bi-weekly, monthly and name of recipient):
UNEMPLOYMENT
WORKER’S COMP
DISABILITY
PENSIONS
RETIREMENT
SPOUSAL
OTHER INCOME
(SSD or Private)
MAINTENANCE
$
$
$
$
$
$
$
DO YOU HAVE ANY OF THE FOLLOWING (please indicate amount):
CASH
CHECKING ACCOUNT
SAVINGS ACCOUNT
LIFE INSURANCE
STOCKS/BONDS
OTHER
Do you own any real property?
YES / NO
What is the estimated value of the property? ___________________________
Write the address of all property:
DO YOU OWN ANY OF THE FOLLOWING (please provide estimated value):
Vehicle
ATV
Snowmobile
Boat
Camper
Other
Make
Model
Value
$
$
$
$
$
$
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