Application For Public Defender Program Form - Chenango County

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Application for Public Defender Program
Court: _______________
Chenango County Public Defender’s Office
nd
County Office Building
26 Conkey Ave.
2
Floor
Court Date:___________
Box 233
Norwich, N.Y. 13815
Phone: (607) 337-1870 Fax: (607) 337-1489
Court Time: __________
Email: publicdefender@co.chenango.ny.us
 Petitioner  Respondent
Criminal
OR
Family Court
_______ Misdemeanors
(Number of each)
NOTES:
_______ Felonies
______
Neglect/Abuse
 Initial/Mod  Violation
CHARGES:
_______ Violations
______
Support
_________________
_______ Probation Violations
______
Custody/Visitation
_______ Parole Violations
______
Paternity
_________________
Co-defendants (List below)
_______
______
Other (specify)_____________________
_____________________________________
Law Guardian____________________________
_________________
_____________________________________
Docket #________________ FF#____________
_________________
_____________________________________
Adverse Party_____________________________
Male 
Female 
PERSONAL INFORMATION
Applicant’s Name ____________________________________________________________
Phone#: ___________________
Applicant’s Address __________________________________________________________
State_____
Zip Code________
Applicant’s Mailing Address ___________________________________________________
State_____
Zip Code________
Social Security Number ____________________________
DOB __________________
Age _____________________
 Single
 Married
 Separated
 Divorced
Marital Status
Spouse’s Name ______________________________
Maiden Name or any other name used __________________________________________________________________________
FINANCIAL INFORMATION
Are you self-employed?
Yes
No
If yes, nature of business: __________________________________________________
Business Address: _______________________
Business Phone: _____________
Earnings last 12 months: ___________
Are you presently employed?
Yes
No
If yes, place of employment ___________________________________________
Gross weekly salary: _________
Earnings to date:___________
How long have you worked here? ______________
Checking Account balance ...........$ ___________________
At Bank __________________________
Savings Account balance .............$ ___________________
At Bank __________________________
Do you receive public assistance? ...
Yes
No
If yes, public assistance number: _______________________________
Do you receive unemployment? ......
Yes
No
If yes, how much per week: ___________________________________
Do you receive social security? .......
Yes
No
If yes, how much per month: __________________________________
.................... 
Do you own a vehicle?
Yes
No
Year, make and amount owed: _________________________________
....................... 
Do you own a home?
Yes
No
Purchase price, year purchased, balance: _________________________
List any other assets, including motorcycles, snowmobiles and other property you own:___________________________________
List any other miscellaneous income you may have (stocks, bonds, inheritances):________________________________________
If you reside with your spouse, are they employed?
Yes
No
:_____________
:____________
Place of employment
Weekly earnings
Total number of people residing in your household and their relationship to you: ________________________________________
________________________________________________________________________________________________________
If under the age of 21, and living with your parents, this section MUST BE FILLED OUT:
Parent(s) Name: ___________________________
Address: _____________________________________________________
Parent(s) Phone: ________________
Parent(s) Income:_________________
Place of employment: ____________________
THIS OFFICE MUST BE NOTIFIED IMMEDIATELY IF YOUR EMPLOYMENT STATUS OR INCOME CHANGES.
I hereby affirm, under penalties of perjury, that the information contained herein is true and correct. I authorize release of information provided herein to the
Chenango County Public Defender’s Office, the Court, the County of Chenango, or their designated agents. I understand that this information may be
investigated, and that the information provided may be used to obtain payment of any fees ordered paid by me, or on my behalf, for representation.
INTENTIONALLY GIVING FALSE INFORMATION ON THIS APPLICATION CONSTITUTES PERJURY. ANY EVIDENCE OF AN
INTENTIONAL MISSTATEMENT REGARDING APPLICANT’S FINANCIAL ELIGIBILITY WILL BE PRESENTED TO THE DISTRICT
ATTORNEY AND PROSECUTED ACCORDINGLY.
I have read and understand the above notice:
Signature of Applicant
Date

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