JDF 208 R 10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT - A PPOINTED COUNSEL, OR GUARDIAN AD LITEM Page 1 of 2 APPLICATION FOR PUBLIC DEFENDER, COURT - APPOINTED COUNSEL, OR GUARDIAN AD LITEM Pursuant to 24721 - 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 Name Mailing Address Street Address (if different) City, State, Zip Phone number Soc. Sec. No. Birthdate Compa ny Mailing Address Street Address (if different) City, State, Zip Phone N umber Position Length of Employment Hours/Week Pay Dates: Pay Rate: $ Other Household Members (Spouse, Partner, Parent, etc.) Other Household Mem Name Relation to Applicant Mailing Address Street Address (if different) City, Sta te, Zip Phone number Soc. Sec. No. Birthdate Company Mailing Address Street Address (if different) City, State, Zip Phone Number Position Length of Employment Hours/Week Pay Dates: Pay Rate: $ Marital Status : Single Married Partner in a Civil Union Separated Divorced /Civil Union Dissolved T otal Number of Dependents (including yourself): Gross Monthly Income (See definitions on reverse for further information . ) Amount Monthly Expenses (See definitions on r everse for further information . ) Amount Self (wages, salary, commission) $ Rent/Mortgage $ Spouse/ Partner/ Other Household Members Groceries Parents (if same household) Utilities Unemployment Benefits Clothing Social Security/Retirement Funds Ma intenance (Spousal/Partner Support) and/or C hild Support Maintenance (Spousal/Partner Support) Medical /Dental Other Income (see Page 2) Other Expenses (identify source) Other Income (see Page 2) Other Expenses (identify source) 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 e ligible for PD/GAL/RPC ( In custody &/or bond allowed Out on bond) or Refer to scoring instrument (C riminal , M isdemeanor , Traffic, J uvenile 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 Colora do for attorney fees spent on my behalf. Client s ignature Date: Signature of judicial officer: Date: Request: granted or denied American LegalNet, Inc. www.FormsWorkFlow.com JDF 208 R 10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT - A PPOINTED COUNSEL, OR GUARDIAN AD LITEM Page 2 of 2 APPLIC A TION FOR PUBLIC DEFENDER, COURT - APPOINTED COUNSEL, OR GUARDIAN AD LITEM General Information It is important that you accurately complete all sections of this form as appropriate based on your pers onal circumstances. If a section does not apply, please write N/A. A. Gross Monthly Income . I ncludes i n come from all members of the household who contribute monetarily to the common support of the household. Income categories to include: Wages, inc luding tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, une mployment benefits, Social Security Disability (SSD), Social Security Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise . Income categories d o not include: from a disability, child support payments , or other public assistance programs. B. Liquid Assets . In clude s cash on hand or in accounts, stocks bonds, certificates of depo sit, equity, and personal property or investments which could readily be converted into cash C. Expenses . Non essential items such as cable television, club memberships, entertai nment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on J DF 20 8 . If you are applying to have your filing fee waived , you may be asked to supply: Copies of the previous three months bank statemen ts, including checking and savings. DO NOT provide originals. Copies of the previous three months pay stubs and/or proof of income must be included. DO NOT provide originals. American LegalNet, Inc. www.FormsWorkFlow.com