Application For Assignment Of Legal Counsel (Page 4 of 4) in pdf

8. Does your spouse work? No

Yes

Give name/address of employer:

______________________________________________________________________

What is his/her present take home salary? _____________________________________

How much did he/she earn during the past twelve (12) months? ___________________

9. Do you have, any other source of income (such as social security, welfare, unemployment,

pension, insurance, veterans, or other payments)? No

Yes

(Specify)

______________________________________________________________________

10.

I am presently in jail and unable to obtain bail.

I am presently released from jail on bail in the amount of $ ____________________

The cost of such bail was defrayed and paid by _________________________________

In the sum of $ ___________________________________________________________

11. I have not previously been represented by an attorney in any case in court except (give name of

attorney, name of case in which you were represented and state whether or not your attorney

was paid in this case and by whom)

______________________________________________________________________

Wherefore, I request that the Public Defender of Northumberland County assign a lawyer to

represent me in this matter without fee or costs to me.

AFFIDAVIT

Commonwealth of Pennsylvania

County of Northumberland

____________________________________, being duly sworn of affirmed to law, deposes and says:

1. I am the defendant in the foregoing matter.

2. I have read the foregoing application and know the contents thereof and the same are true to

my own knowledge, except as to matter therein stated to be alleged as to persons other than

myself, and as to those matters I believe to be true.

3. This Affidavit is made to inform the Public Defender of Northumberland County as to my status

of indigency and to induce the Public Defender to assign counsel to me as an indigent defendant

for my defense against the criminal charges that have been made against me.

4. In making, this affidavit I am aware that the crime of perjury is a felony of the third degree and

that the punishment is imprisonment for not more than seven years or a fine of not more than

$5,000.00 or both.

I VERIFY that the statements made in this affidavit are true and correct. I understand the false

statements herein are made subject to the penalties of 18 Pa. C.S. S4904 relating to unsworn

falsification to authorities.

_____________________________________

___________________________________

Witness

Defendant

___________________________________

Date

Application For Assignment Of Legal Counsel Page 4

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