Application Affidavit For Public Defender Services And Promise To Pay

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APPLICATION/AFFIDAVIT FOR PUBLIC DEFENDER SERVICES AND PROMISE TO PAY
COMPLETE ONLY IF REQUESTING PUBLIC DEFENDER REPRESENTATION
Last Name: ______________________________ First Name: ________________________________MI: _____
Date of Birth: _ _ /_ _ /_ _ _ _
SSN: _ _ _ - _ _ - _ _ _ _
Address: _______________________________________ City: __________________ State:____ Zip:_________
Phone Number: ( _ _ _ ) _ _ _ - _ _ _ _
Alternate Number: ( _ _ _ ) _ _ _ - _ _ _ _
i
Email Address
: ______________________________________________________________________________
What are the charges against you?: ______________________________________________________________
In what county(ies) are you facing charges?: _______________________________________________________
Case Number(s): _____________________________________________________________________________
Are you in jail?: Yes _____ No _____
If you are out on bond, what bond did you make?: __________________________________________________
What amount has actually been paid?: _________________
How much is still owed?: __________________
What was the source of funds used to pay the bond?: _______________________________________________
ELIGIBILITY DETERMINATION FOR QUALIFYING CASES
1. Do you have any cash, bank accounts, equity in real estate, stocks, bonds, jewelry, cash value in life
insurance policy or other financial assets available for use in posting bond or hiring an attorney?
a.
Yes _____ List by type and value: _________________________________________________________
_____________________________________________________________________________________
b. No _____
2. Are you employed?:
a. Yes _____ Go to Question #4
b.
No _____ Go to Question #3
Are you receiving any type of public assistance?
3.
(do not include Social Security, Disability, or Unemployment Compensation)
a. Yes _____ If so, what type? _______________________________
If Yes, Skip #4 & #5
b.
No _____ Go to Question #4
Eligible For Services - Go To Page 2
4. How many dependents do you have?:
_______
5. Please list all sources of current income.
:
May leave blank if dollar amount is $0.00
a. Monthly gross income from job
$_____________
If your annual income is equal to or
1
b. Spouse’s monthly income
$_____________
less than the Federal Poverty
2
c. Parent’s monthly income
$_____________
Guidelines for your family size, you are
d. Monthly public assistance
$_____________
eligible for Public Defender Services.
e. Monthly Unemployment Compensation $_____________
If your annual income is more than the
f.
Monthly Social Security
$_____________
Federal Poverty Guidelines for your
g. Other monthly retirement/pension
$_____________
family size, you MAY be eligible
h. Monthly disability income
$_____________
depending on individual
i.
Other monthly income
$_____________
circumstances.
Total: $_____________
Go To Page 2 – Application Must Be Signed
1
Unless spouse is the alleged victim.
2
If full time student, dependent upon parent or parent posted bond, unless parent is the alleged victim in the crime charged.
Page 1

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