SAMPLE RECOUPMENT POLICY _____________________ County Indigent Defense Fee/Cost Recoupment Policy 1. The Court shall review each defendant’s indigent status and determine if recovery of assigned counsel fees or public defender costs is appropriate. The Court may waive the fees if it is determined that the imposition of such would result in an undue hardship on the client. 2. The Court may order further income verification to determine eligibility. The income verification fee shall be $25.00, subject to waiver by the Court in the case of undue hardship. 3. The Court shall order when the reimbursement fee shall be due. 4. The Court may request that the defendant sign an agreement regarding the recoupment amount. The agreement form to be used is attached to this policy. 5. Persons shall pay according to the following schedule, determined by the highest degree of offense charged: Felonies Misdemeanors Abuse/Dependency/Neglect Cases Other Juvenile Cases $100.00 $ 50.00 $100.00 $ 50.00 6. Payments shall be remitted to the county Clerk of Courts, payable by certified check or money order (cash not accepted) made payable to the County Treasurer. American LegalNet, Inc. www.USCourtForms.com AGREEMENT TO REIMBURSE LEGAL COSTS/FEES I, ____________________________hereby request counsel to represent my interests in ____________________________________________________ Court; Case No(s). ___________________________________________________________. I certify that the financial information contained in the Financial Disclosure Statement attached hereto is true and accurate to the best of my knowledge. I further certify that I have been unable to retain private counsel and hereby request the ______________ County Public Defender or assigned counsel to represent my interests herein. I agree that I may reasonably be expected to reimburse _____________ County for some part of the costs of representation and, as consideration for said representation. I hereby agree to pay $___________ by certified check or money order payable to the ______________County Treasurer as reimbursement for the costs of the legal services rendered to me. I agree said amount is reasonable based on my income and/or assets and further agree said amount shall be paid as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I also understand that if it is determined by the ______________ County Public Defender, State Public Defender, assigned counsel or by the Court, that I was not entitled to the legal representation provided to me, I may be required to reimburse the County for the full costs thereof. Date:__________________________ Signed: ___________________________ Witness: ___________________________ American LegalNet, Inc. www.USCourtForms.com SAMPLE RESOLUTION Whereas, the Office of the Ohio Public Defender has by Rule OAC 120-1-03 adopted regulations for the appointment of counsel for the indigent; and, Whereas, pursuant to this rule, the Board of County Commissioners needs to adopt a verification procedure and a plan to recoup all or part of the cost of counsel for persons who meet certain income guidelines. It is hereby resolved that: The Courts of this county shall make the appointment of counsel, either private assigned counsel or the County Public Defender, in accordance with the rules established by the Ohio Public Defender Commission and the State Public Defender to enable this county to receive reimbursement from the state for a part of the indigent defense costs. The Courts of this county assigning indigent defense counsel shall, in accordance with OAC 120-1-03, order that a part or all of counsel fees be repaid to the County where appointment is made and the defendant falls into the income guidelines set forth in the rule (currently 125 percent to 187.5 percent of the poverty threshold). Payments shall be made pursuant to the _______________ County Indigent Defense Fee/Cost Recoupment Policy, a copy of which is hereby attached to this resolution. This resolution shall be effective for all cases with an appointment date of ______________ or later. Board of County Commissioners ______________________________ ______________________________ ______________________________ American LegalNet, Inc. www.USCourtForms.com VERIFICATION OF INCOME AUTHORIZATION FOR RELEASE OF INFORMATION TO WHOM IT MAY CONCERN: I am unable to provide all necessary background information pertinent to my case now pending in _________________ County. I, therefore, authorize and direct the _________________ COUNTY PUBLIC DEFENDER or my ASSIGNED COUNSEL __________________________to contact the (attorney name) following sources for additional information: _____Employer _____Financial Institutions _____Insurance Companies _____Law Enforcement Agencies _____Military _____Employers _____Veterans Administration _____Social Security Administration _____Internal Revenue Service _____Physicians & Medical Institutions _____Any agency of the State of Ohio _____Any agency of ______________ County _____Schools _____Correctional Facilities _____Other _____Payee/Trustee/Guardian I hereby authorize and direct those sources checked above to release any and all information requested by the agents of the County Public Defender or my above named assigned counsel. It is my understanding that all information concerning me will be regarded as confidential. This document has been read by me/to me and its purpose explained to my satisfaction. NAME: _________________________________ Address: _________________________________ _________________________________ Phone: _________________________________ DOB: ___________ SS# ________________ Signature: ________________________________ Witnessed: ________________________________ Date: ________________________________ Information requested: ________________________________________________________________________________ _____________________________________________________________________________ Return information to American LegalNet, Inc. www.USCourtForms.com MONTHLY RECOUPMENT REPORT for ________________ County Funds Collected from Indigent Clients/State Reimbursement _____________ (Date of Report) Date Client Paid Case # Client Name Month Paid by State % Paid by State Amount Client Paid Amount Due State % $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ Total Paid to State Page ____ of ____ $ $ Doc.#168372 American LegalNet, Inc. www.USCourtForms.com MONTHLY RECOUPMENT REPORT For ______________ County Funds Collected from Indigent Clients/State Reimbursement __________ (Date of Report) Date Client Paid Case # Client Name Month Paid by State % Paid by State Amount Client Paid Amount Due State 11/01/2003 03cr5656 Smith, Joe June, 03 33% $ 60.00 $ 19.80 11/01/2003 03cr3256 Smith, Thomas June, 03 33% $ 50.00 $ 16.50 12/15/2003 03cr2555 Walker, Will Aug, 03 40% $ 200.00 $ 80.00 01/01/2004 03cr6565 Anderson, Mark Nov, 03 39% $ 30.00 $ 11.70 01/01/2004 03cr6566 Anderson, Kim Dec, 03 37% $ 25.00 $ 9.25 01/02/2004 03cr6567 Mason, Tom Dec, 03 41% $ 200.00 $ 82.00 01/03/2004 03cr6568 Smith, Bob Jan, 04 30% $ 50.00 $ 15.00 01/04/2004 03cr6569 Mackay, Ron Feb, 04 30% $ 60.00 $ 18.00 % $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ Total Paid to State Page ___ of ___ $ $ Doc#195492 American LegalNet, Inc. www.USCourtForms.com OHIO PUBLIC DEFENDER INDIGENT CLIENT ELIGIBILITY GUIDELINES 2004 ALL FIGURES BASED ON GROSS INCOME. Annual Income Household Size 1 2 3 4 5 6 7 8 each additional Monthly Income Bi-Weekly Income 125% $ 11,638 $ 15,613 $ 19,588 $ 23,563 $ 27,538 $ 31,513 $ 35,488 $ 39,463 187.5% $ 17,456 $ 23,419 $ 29,381 $ 35,344 $ 41,306 $ 47,269 $ 53,231 $ 59,194 125% $ 970 $ 1,301 $ 1,633 $ 1,964 $ 2,295 $ 2,626 $ 2,958 $ 3,289 187.5% $ 1,455 $ 1,952 $ 2,448 $ 2,945 $ 3,442 $ 3,939 $ 4,436 $ 4,933 $ $ $ $ $ $ $ $ 125% 448 600 753 906 1,059 1,212 1,365 1,518 $ $ $ $ $ 153 3,975 5,963 331 497 Weekly Income 187.5% $ 671 $ 901 $ 1,130 $ 1,359 $ 1,589 $ 1,818 $ 2,047 $ 2,277 125% $ 224 $ 300 $ 377 $ 453 $ 530 $ 606 $ 682 $ 759 187.5% $ 336 $ 450 $ 565 $ 680 $ 794 $ 909 $ 1,024 $ 1,138 $ $ $ 229 76 Based on poverty guidelines determined by the U.S. Dept. of Health & Human Services SOURCE: http://aspe.hhs.gov/poverty/04poverty.shtml Doc #175155 American LegalNet, Inc. www.USCourtForms.com 115 FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY Name I. PERSONAL INFORMATION Case No. Mailing Address City D.O.B. State ZIP Phone ( ) Message Phone (within 48 hours) ( ) Residence (if different from above) Name 1) II. OTHER PERSONS LIVING IN HOUSEHOLD Relationship Name 3) Age 2) Age Relationship 4) III. MONTHLY INCOME/EMPLOYMENT INFORMATION Self Spouse Household Members Type of Income Employment (Gross) Total Unemployment Worker’s Comp. Pension Social Security Child Support Works First/TANF Disability Other Other Employer’s Name (for all household members) SUBTOTAL A Address IV. ALLOWABLE EXPENSES Type of Expense Amount Child Support Paid Out Child Care (if working only) $ Phone ( ) V. TOTAL INCOME Total Monthly Income – Total Allowable Expenses = Total Income Transportation for Work - Medical/Dental Medical & Associated Costs Of Caring for Infirm Family Members SUBTOTAL A SUBTOTAL B $ GRAND TOTAL C Insurance $ $ SUBTOTAL B $ Type of Asset Real Estate / Home VI. ASSET INFORMATION Describe / Length of Ownership / Make, Model, Year (where applicable) Price:$ Date Purchased: Equity: Estimated Value Stocks / Bonds / CD’s Automobiles Trucks / Boats / Motorcycles Other Valuable Property Cash on Hand Money Owed to Applicant Other Checking Acct. (Bank / Acct. #) Savings Acct. (Bank / Acct. #) Credit Union (Name / Acct. #) GRAND TOTAL D $ American LegalNet, Inc. www.USCourtForms.com VII. MONTHLY LIABILITIES/OTHER EXPENSES Type of Liability Rent / Mortgage VIII. GRAND TOTALS Amount Grand Total C Total Monthly Income Food Electric Gas Fuel Grand Total D Telephone Total Assets Cable Water / Sewer / Trash Credit Cards Loans Taxes Owed Total Monthly Liabilities Other Grand Total E and Other Expenses GRAND TOTAL E IX. AFFIDAVIT OF INDIGENCY I, _________________________________________________________________ being duly sworn, say: 1. I am financially unable to retain private counsel without substantial hardship to me or my family. 2. I understand that I must inform my attorney if my financial situation should change before the disposition of my case. 3. I understand that if it is determined by the county, or by the Court, that legal representation was provided to for me to which I was not entitled, I may be required to reimburse the county for the costs of representation provided. Any action filed by the county to collect legal fees hereunder must be brought within two years form the last date legal representation was provided. 4. I understand that I am subject to criminal charges for providing false financial information in connection with the above application for legal representation pursuant to Ohio Revised Code Sections 120.05 and 2921.13. 5. I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge. Client’s Signature Date Notary Public: Subscribed and duly sworn before me according to law, by the above named applicant this ______ day of _______________________, _______ , at _______________________, County of ___________________________ and State of _________________. Notary’s Signature X. JUDGE CERTIFICATION I hereby certify that above-noted client is unable to fill out and/or sign this financial disclosure/ affidavit for the following reason: ___________________________________________________________________ . I have determined that the applicant meets the criteria for receiving court appointed counsel. Judge’s Signature Date American LegalNet, Inc. www.USCourtForms.com