APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM
Pursuant to §21-1-103(3), C.R.S., a processing fee of $25.00 may be collected by the court upon final disposition of this case.
Case number: _____________________Court Room: _________________________________________ District: ____________________________
Most serious charge: ________________________________________________ Next hearing date/Type: __________________________________
All sections must be completed. Print neatly. If an item does not apply, write N/A.
Applicant’s Employer
Applicant
Name ____________________________________________________
Company _________________________________________________
Mailing Address ____________________________________________
Mailing Address ____________________________________________
Street Address (if different) ____________________________________
Street Address (if different) _______________________________________
City, State, Zip _____________________________________________
City, State, Zip _____________________________________________
Phone number _____________________________________________
Phone Number _____________________ Position _________________
Soc. Sec. No. ____________________ Birthdate __________________
Length of Employment _________________ Hours/Week ___________
Driver’s License No. ____________________ State ________________
Pay Dates: _______________________ Pay Rate: $_______________
Other Household Member’s Employer
Other Household Members (Spouse, Partner, Parent, etc.)
Name ____________________________________________________
Company _________________________________________________
Relation to Applicant _________________________________________
Mailing Address ____________________________________________
Mailing Address ____________________________________________
Street Address (if different) _______________________________________
Street Address (if different) ___________________________________
City, State, Zip _____________________________________________
City, State, Zip _____________________________________________
Phone Number ___________________ Position __________________
Phone number _____________________________________________
Length of Employment ________________ Hours/Week ____________
Soc. Sec. No. ________________________ Birthdate ______________
Pay Dates: _______________________ Pay Rate: $_______________
Driver’s License No. ______________________ State ______________
Marital Status: Single Married Partner in a Civil Union Separated Divorced/Civil Union Dissolved Total Number of Dependents (including yourself):__
Gross Monthly Income (See definitions on
Amount
Monthly Expenses (See definitions on reverse for further
Amount
reverse for further information.)
information.)
Self (wages, salary, commission)
$
Rent/Mortgage
$
Spouse/Partner/Other Household Members
Groceries
Parents (if same household)
Utilities
Unemployment Benefits
Clothing
Social Security/Retirement Funds
Maintenance (Spousal/Partner Support) and/or Child Support
Maintenance (Spousal/Partner Support)
Medical/Dental
Other Expenses (identify source)
Other Income (see Page 2)
Other Expenses (identify source)
Other Income (see Page 2)
Total Household Income
$
Total Expenses
$
Assets
Amount
Description
Savings Account Balance
$
Name of Bank:
Checking Account Balance
Name of Bank:
Value of Vehicles
Year and Model:
Value of Recreation Vehicles
Amount Owed: $
Value of House
Type:
Value of Other Property
Type:
Value of Stocks, Bonds, Mutual Funds
Type:
Value of Other Investments
Year and Model:
Total Assets
$
Convertible to Cash = $
References:
1.
Name/Address/Phone ____________________________________________________________________________________
2.
Name/Address/Phone ____________________________________________________________________________________
Guidelines:
At or below or
Above or
Automatically eligible for PD/GAL/RPC (
In custody &/or bond allowed
Out on bond ) or
Refer to scoring instrument (Criminal, Misdemeanor, Traffic, Juvenile Delinquency cases )
Signature of investigator/clerk/PD:________________________________________
Date: ___________________________
I swear under penalty of perjury that the above-contained information is true and complete. I also understand that if the court grants this
request, I may later be ordered to reimburse the State of Colorado for attorney fees spent on my behalf.
Client signature ____________________________________________________
Date: __________________________
Signature of judicial officer: ____________________________________________
Date: ___________________________
Request:
granted or
denied
JDF 208
R10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM
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