In the State Court of Chatham County 133 Montgomery St. Savannah Georgia 31401 Ph 652-7225 Fax 652-7241 NOTICE OF JUDICIAL APPOINTMENT / REQUEST FOR COUNSEL TO REPRESENT AN INDIGENT DEFENDANT State of Georgia Vs ________________________________________ Case # ___________ Defendant The above requested counsel through the Public Defender's Office. Please evaluate and advise status. named defendant has requested counsel through the Public Defender's Office. Please evaluat Said defendant has In the above cited matter, the Hon. ________________________, did from the bench, determine that the defendant is indigent and therefore, on ____________ (date) at ______M appointed counsel to represent said defendant as an indigent. The following information is hereby provided for action by Public Defender, EJD.AP APPOINTED COUNSEL Attorney ______________________________ Address _______________________________ City State Zip _______________________________ GA Bar #________ Attorney Code_______ E-Mail _______________________________ Telephone____________ Fax_____________ DEFENDANT Name _______________________________ Address _______________________________ City State Zip _______________________________ DOB_____________ Race______ Sex_______ SSN _______________ GA DL #_____________ Phone____________ Arrest Date ___________ CHARGES Charge 1 __________________________________________________________________________ Charge 2 __________________________________________________________________________ Charge 3 __________________________________________________________________________ Charge 4 __________________________________________________________________________ Charge 5__________________________________________________________________________ Please accept this NOTICE/REQUEST for indigent counsel for the record and proceed accordingly. If this is a REQUEST for counsel, please advise status within five days of this notice. If an APPOINTMENT, this document is counsel's entry of appearance and will be included in the electronic and paper records of this case. Filed in OPEN COURT on _________________. FOR THE COURT : Notice provided to By: Hand Office of the Public Defender Appointed Counsel Defendant’s Case File & JIMS Fax E-Mail ___________________________ Deputy Court Clerk State Court of Chatham County US Mail interOffice Date Completed Clerk's _______________ Initials _______________ ________ _______________ aa-IndigentDefenseAppointment 07-06 American LegalNet, Inc. www.FormsWorkflow.com