AppointedCounsel&AffidavitOctober2017.doc PLEASE COMPLETE APPLICATION IN FULL. MISSING INFORMATION WILL DELAY PROCESSING. APPLICATION FOR APPOINTED COUNSEL & AFFIDAVIT OF FINANCIAL RESOURCES GWINNETT JUDICIAL CIRCUIT Name I am [ ] in the Gwinnett jail [ ] the PWC [ ] released on bond. Arrest date: Address: City State Zip Code Telephone (day) Telephone ( night ) Inmate ID # D ate of Birth List the Gwinnet t County offense(s) against you. List the citation, warrant, indictment or accusation numbers, if known: Offense(s) Case # Offense(s) Case # The court in which the most current charges are pending: [ ] Superior Ct. - felony [ ] State Ct. - misdemeanor [ ] Magistrate Ct. - warra nts [ Ct. - traffic tickets [ ] Probation Revocation only [ ] No attorney has been appointed to represent me. [ ] I have applied for appointed counsel before on these offense(s). [ ] I have appointed counsel on other pending charges and wish to have that attorney appointed on the new charges listed above. Attorney name . [ ] I am seeking a replacement of my retained attorney for the following reasons: (Attach additional sheets, as necessary): I want the court to provide me with an attorney to defend me against the above charges. I am providing the info rmation in this affidavit to permit the court to determine if I qualify for a court appointed attorney, who would be paid by Gwinnett County. Employment I am [ ] employed [ ] unemployed since (date): [ ] My employer is Telephone # [ ] My take home pay is $ per [ ] week [ ] 2 weeks [ ] month [ ] other, as follows: Sources of Income [ ] welfare $ [ ] unemployment $ [ ] disability $ [ ] retirement$ [ ] child support $ [ ] other $ ] week [ ] 2 weeks [ ] month [ ] other: [ ] I have minor children [ ] living in my home [ ] for whom I provide support. They are ages: (#) other persons live in my home. They [ ] are not related to me [ ] are related to me. The take home pay of relatives living in my home is $ per [ ] week [ ] 2 weeks [ ] month [ ] other: American LegalNet, Inc. www.FormsWorkFlow.com AppointedCounsel&AffidavitOctober2017.doc I own the following assets & property: (Answer EACH question) Home/ land [ ] yes [ ] n o If yes, the value is $ & I owe $ net value $ Motor vehicles [ ] yes [ ] no If yes, their value is $ & I owe $ net value $ Boats [ ] yes [ ] no If yes, their value is $ & I owe $ net value $ Checking/Savings accounts [ ] yes [ ] no If yes, the total of all balances is $ I own these other assets & properties, such as antiques, jewelry, coins, collectibles, stocks, bonds, etc ... Their value is: List the amounts you owe for any extraordinary or unusual living expenses, child support payments and/or medical expenses. I [ ] have [ ] have not tried to hire an attorney. I can pay $ for my legal defense. fees paid on my behalf, if I am able, or if a court determines that I am able to reimburse the county. I under stand that, pursuant to O.C.G.A. 247 15 - 21 - A - 6, a $50 application fee for indigent defense representation will be assessed unless waived by the court. I have read, or had read to me, the above questions and statements. I swear that the answers I have given are true and correct. I also understand that a false answer to any question herein may result in my being charged with a crime for making such false statement(s). Signature of Applicant: ORDER OF THE COURT Having considered the above application for appointment of counsel & affidavit of financial resources, I find that the defendant [ ] is [ ] is not indigent by the guidelines of the Indigent Defense Counsel of Georgia & appropriate court rules . [ ] is [ ] is not entitled to have appointed counsel on his/her behalf. [ ] is [ ] is not required to pay a $50 application fee. [ ] A s a condition for the bond, the $50 application fee shall be paid to the Sheriff at the time the defendant posts bond. Said amount shall be paid from the Registry of the Sheriff to the Registry of the Clerk of Court for [ ] Magistrate [ ] State [ ] Superior Court. [ ] is currently rep resented by attorney , this appointment remains in effect. [ ] has withdrawn his/her application. [ ] a hearing has been scheduled. [ ] the case has been adjudicated. So ordered, this day of , 20 . Judge, [ ] Superior [ ] State [ ] Magistrate American LegalNet, Inc. www.FormsWorkFlow.com