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Application For Attorney Services (Criminal Court) Form - St. Lawrence County Indigent Defense Page 4

MONTHLY EXPENSES (Proof of expenses may be required after the application has been filed):

Revised 2/5/2015

MORTGAGE

RENT

PROP. TAXES

UTILITIES

CABLE

TELEPHONE

GARBAGE

WATER/SEWER

AUTO PAYMENT

CAR INS.

LIFE INS.

HOME INS.

CREDIT CARDS

LOANS

HEALTH INS.

MEDICAL

HOME FUEL

FOOD

PHARMACY

CHILD SUPPORT/

ALIMONY

PLEASE READ THE FOLLOWING STATEMENT AND SIGN THIS DOCUMENT SWEARING THAT ALL THE INFORMATION PROVIDED IS ACCURATE, TO THE BEST OF

YOUR KNOWLEDGE:

By signing this, you are authorizing the Office of Indigent Defense to verify the facts on your application and authorizing any agency or third party to release

information about you to the Office of Indigent Defense and the Court for the purpose of determining eligibility.

If there is a change in your financial circumstances, you are required to report this change to the attorney assigned to represent you immediately. If the change in

your circumstances makes you financially able to obtain counsel or to make partial payment for representation or other services, the court may terminate the

assignment of counsel or authorize payment to St. Lawrence County.

When signing this application you are making a sworn statement that the information in the application is true and accurate.

In a written instrument, any person who knowingly makes a false statement which such person does not believe to be true has committed a crime under the laws of

the State of New York punishable as a Class A Misdemeanor (PL §210.45).

Affirmed under the penalties of perjury this __________ day of ____________________ , 20_____

_____ __________________

_______

____________________

Print Name

Signature

Date

Did you include proof of income or assistance with your application?

Pay Stubs

SNAP/Public Assistance Benefit Letter

Unemployment Benefit Letter