Standart Council Application For Public Defender Services Form - Georgia Public Defender
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2GEORGIA PUBLIC DEFENDER
STANDARDS COUNCIL
APPLICATION FOR PUBLIC
DEFENDER SERVICES
Application Date: _____/_____/_____
Date of Arrest: _____/_____/_____
Date of Offense: ____/_____/_____
In Jail:
YES / NO
Court: _________________ County: _______________________
Court Date: ______________
NAME: Last__________________________________
First _____________________________ Middle _____________________________
OTHER NAME(S): ____________________________________ CASE NUMBER(S): ______________________________________________
CHARGES: ____________________________________________________________________________________________________________
CO-DEFENDANTS: ____________________________________________________________________________________________________
Address: _______________________________________ City: _____________________________ State: ___________ Zip:__________________
Telephone No(s): Home: ______________________ Cell: _________________________ Work: _______________________________________
Date of Birth: ________________________ Social Security Number: ______-______-______ Race: _______________ Sex: __________________
The person who can always reach you: Name: ________________________________________ Telephone: _______________________________
Address: _______________________________________________________________________________________________________________
MARITAL STATUS: Single / Divorced / Separated / Married/ Living with the parent of your children
Spouse’s Name: __________________
Is your spouse employed? Yes / No If yes, Where? ___________________________________________________________________________
Spouse’s Income: $____________________________ week/ two weeks/ month/ year (circle one)
Ages of your children who live in the house with you: __________________________________________________________________________
List any other dependents: ________________________________________________________________________________________________
EMPLOYMENT: Are you employed (including self-employment, part-time work, or “odd jobs”)? Yes / No
If yes, employer name, address, telephone number: _____________________________________________________________________________
Job title: __________________________________________________________________ Length of employment _________________________
If unemployed or employed less than one year at this job, state the date and income of your most recent prior employment. ____________________
INCOME: Net income (total income, minus deductions required by law and child support payments deducted from paycheck)
$_____________________ week/ two weeks/ month/ year (circle one)
If child support not deducted from check, state amount of child support obligation: $ ______________week/ month
If incarcerated, do you have income while in jail? Yes / No Amount $ _____________
Do you receive child support? Yes / No Amount. $____________________
Do you receive unemployment or workers compensation? Yes / No Amount $__________________
Do you receive: Military, VA, Social Security, SSI, TANF, Food Stamps, or Retirement benefits? Yes / No. Amount: $ _____________________
If you do not pay your own basic living expenses, state the relationship of the person who does.__________________________________________
Are you disabled? Yes / No If yes, what type of Disability: _____________________________________________________________________
Does anyone else claim you as a dependent for tax purposes? Yes / No If yes, who__________________________________________________
Other payments you receive from any source __________________________________________________________________________________
THINGS YOU OWN: Cash, checking accounts, savings accounts, retirement accounts, inmate accounts: $________________________________
Motor vehicles: State year, model and make: _____________________________________________ Est.Value: $________________________
Is any real estate titled in your name? Yes / No
Equity: $_____________________________
Other assets or property, other than usual and customary household furnishings. List and state est.value. __________________________________
PROBATION: Court ordered monthly payment. $_______________________
UNUSUAL EXPENSES: Unusual expenses (other than basic living expenses). Specify type and amount. _________________________________
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