Family Court Application - Saratoga County Family Court Page 2
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2THIS FORM MUST BE COMPLETED IN FULL. PLEASE PRINT CLEARLY.
APPLICATION FOR COUNSEL – FAMILY COURT
1. NAME: _________________________________________________________________________________________________________________
Email ____________________________________________AGE: ___________ DOB: _________________ TEL. NO. ______________________
ADDRESS: _______________________________________________________________CITY ______________________ ZIP: ________________
2. Are you married? Y (___) N(___) Are you separated? Y (___) N(___) Are you a student? Y (___) N(___)
3. Are you employed? Y ( ) N ( ), if yes: Name of Employer: _____________________________________________________________________
Employer's Phone Number:________________________ How long have you been employed________________
4. How much is your weekly take‐home pay $____________________ If you receive tips, average you receive weekly: ____________
DO NOT LIST YOUR SPOUSE AS A DEPENDANT OR THEIR INCOME UNLESS HE/SHE LIVES IN THE HOME
5. How many dependents do you have (include yourself/spouse)? _____ How many of them do you support? ___________
6. If you are not separated, is your spouse employed? _____If employed, what is your spouses’weekly take‐home pay? _______________
7. If you show no income, what is your present means of support? ______________________________________________________________
8. Does your spouse/parent whom you live with receive any of the following? Disability $__________Social Security $__________
Worker’s Compensation $__________ Unemployment $_____________ Social Services $__________ Support/Alimony $_____________
TOTAL AMOUNT $ __________________
9. Complete the following monthly expenses
: (IF YOU NEED ADDITIONAL SPACE, USE THE BACK OF THIS FORM)
Mortgage _______________ Rent ______________ Food _______________ Credit Card ______________
Telephone ______________ Loan ______________ Auto _______________ Insurance ________________
Electric _________________ Cable _____________ Medical ____________ Other ___________________
TOTAL AMOUNT $ __________________
10. Do you share the payment of these expenses with someone else? Y (___) N(___)
11. Do you have any of the following? Cash on Hand Y (___) N(___); Checking Account Y (___) N(___)
Savings Account Y (___) N(___) Total Cash (Cash on Hand, Checking, Savings) $____________________
12. Do you own a house, mobile home or automobile? Y (___) N(___)
What is the value of your house/mobile home? $___________ What is the current balance $_______________
Automobile: Make_________ Model __________ Year _______ What is the balance of the loan(s) $_______________
13. Do you own any other assets of any kind? Y (___) N(___) If yes, describe in detail and give the value of these assets:
________________________________________________________________________________________________________________________
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT THE ANSWERS GIVEN ARE TRUE AND CORRECT.
SIGNED: ______________________________________________________________________________________ DATE: ______/______/______
FOR COURT USE ONLY
: Petitioner: ________________________________ Respondent: __________________________________
Part I ______ Part II _______ Docket No.: __________________________________ File No.: ___________ Return Date: _____/______/______
Time: _______________ Nature of Proceeding: ________________________________________________________________________________
Date Received by Court: _____/______/______ Received By: __________________________________________________
FOR PUBLIC DEFENDER USE ONLY
TO: ________________________________________________________
DATE: _____/______/______
Your Application for Counsel has been:
(_____) 1. Approved and your case has been assigned to: ___________________________________________________________
The attorney’s phone number is _________________________________
(_____) 2. Approved for the following services only: ________________________________________________________________
(_____) 3. Denied (check reason for denial)
a. Not Indigent (_____) b. Visitation only real issue (_____)
c. No action currently pending (_____) d. Incomplete or insufficient information (_____)
e. No authorization for Public Defender services (_____)
If you wish to appeal your denial or for further information contact:
SARATOGA COUNTY PUBLIC DEFENDERS OFFICE
40 MCMASTER ST. BALLSTON SPA, NY 12020
TELEPHONE (518) 884‐4795 EMAIL: pd@saratogacountyny.gov
IF YOU ARE APPOVED FOR PUBLIC DEFENDER SERVICES, THE ATTORNEY WILL ATTEMPT TO CONTACT YOU
APPROXIMATELY ONE WEEK BEFORE YOUR COURT DATE.
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