APPLICATION FOR THE SERVICES OF THE PUBLIC DEFENDER NAME: Last ADDRESS: First Middle Street STATE Yes ZIP Date of Birth: TIME AT THIS ADDRESS: years months HOME PHONE ( ) Apt. # CITY Do you have a spouse? Social Security Number: CELL PHONE ( ) No How many children live in the household? ____________________ * IT IS YOUR RESPONSIBILITY TO NOTIFY THE COURT OF ANY ADDRESS CHANGE * EMPLOYMENT INFORMATION SELF SPOUSE Name of Spouse: ___________________________ Name of Employer #1 Work Phone Number Hourly Rate of Pay ( ) $_____per hour _____hrs/week ( ) $______per hour _____hrs/week Name of Employer #2 Work Phone Number ( ) ( ) $_____per hour _____ hrs/week $______per hour _____ hrs/week OTHER INCOME SELF SPOUSE Public Assistance(MFIP/GA) $ per month $ per month Social Security Benefits $ per month $ per month Unemployment or Worker’s Comp $ per month $ per month Child Support $ per month $ per month Other Income (retirement/pension/veteran’s $ per month $ per month Hourly Rate of Pay benefits/, etc…) ASSETS (INCLUDING JOINT ASSETS IF MARRIED) Bank Accounts (Savings, Checking, Money market, etc.) $ Stocks, Bonds, Notes $ Do you own a home? Yes No Amt of monthly mortgage payment $__________ Value of home $______________ Do you own other property? Yes No Value of other property $_________________________ Do you own a vehicle? Yes No If yes, amount of monthly vehicle payment $ _________________________ Vehicle Information: Make: ________________________ Model: _______________________ Year _________________ Indicate if you own any of the following: Watercraft ATV Snowmobile RV Trailer If yes, amount of monthly payment(s) $ _____________________ Value $________________________________ Are there any extraordinary expenses that you would like noted on this application? Yes No $ _________ per month Describe: Request and Oath I request the Court to appoint an attorney to represent me. I affirm, or swear, on penalty of perjury that I am presently unable to hire an attorney to represent me and that my answers to the above questions are complete and truthful. Applicants Signature: ____________________________ Date: ___________________________________ ORDER The First District Public Defender is assigned to represent the defendant. A $75 co-pay plus $__________ in public defender fees must be paid within 30 days of defendant’s sentencing or disposition date. Next Hearing Date__________________________________________________________ Application for public defender is DENIED. Dated: Judge of District Court Revised 07/09 American LegalNet, Inc. www.FormsWorkFlow.com