OFFICE OF THE PUBLIC DEFENDER COURTHOUSE SQUARE 100 WEST BEAU STREET, SUITE 605 WASHINGTON, PENNSYLVANIA 15301 PHONE NUmBER: {724} 228-6818 FAX NUmBER: (724) 250-6516 IF YOU ARE PLANNING TO MAKE APPLICATION WITH THE PUBLIC DEFENDER'S OFFICE, PLEASE TAKE THE FOLLOWING WITH YOU TO THEIR OFFICE. CRIMINAL COMPLAINT SHEET AFFIDAVIT OF PROBABLE CAUSE PROOF OF INCOME NO APPLICATION WILL BE ACCEPTED WITHOUT THE ABOVE INFORMATION NO EXCEPTIONS **APPLICATIONS MUST BE MADE AT LEAST 3 BUSINESS DAYS** **PRIOR TO A SCHEDULED HEARING DATE** IF YOU HIRE PRIVATE COUNSEL, PLEASE NOTIFY THIS OFFICE IMMEDIATELY. YOU MUST CONTACT OUR OFFICE OF ANY ADDRESS OR TELEPHONE CHANGES American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY P/D NO. DATE: SOURCE: DATE RECEIVED: NAME: HOME ADDRESS: CITY: PHONE NO.: STATE: ZIP CODE: - SOCIAL SECURITY NO.: E-MAIL ADDRESS: ___________________________________________________________ DATE OF BIRTH: MARITAL STATUS: ADDRESS: (if different) NAME AND AGES OF CHILDREN: AGE: NAME OF SPOUSE: SPOUSE'S PH. NO. SEX: MALE/FEMALE IF SINGLE, NAME OF PARENTS/NEAREST RELATIVE: PARENTS ADDRESS: INCIDENT DATE: TOWNSHIP: PLACE: CITY: PHONE NO. TIME: STATE: WHAT IS YOUR BOND STATUS? BOND PAID BY WHOM? I AM UNABLE TO OBTAIN COUNSEL TO DEFEND ME BECAUSE: MAG. HEARING DATE: CASE NO.: PRESENT CHARGE: TIME: OTN: MAGISTRATE: 2 American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT ARE YOU EMPLOYED? EMPLOYER: GROSS MONTHLY WAGES If married, IS YOUR SPOUSE EMPLOYED? If yes, NAME, ADDRESS AND PHONE NO. OF NAME, ADDRESS AND PHONE NO. OF SPOUSE'S EMPLOYER: SPOUSE'S GROSS MONTHLY INCOME: IF UNEMPLOYED, WHEN AND WHERE DID YOU WORK LAST? IF UNEMPLOYED, SOURCE OF INCOME: CASE WORK (D.P.A.): AMOUNT: WHAT OFFICE: AMOUNT: VALUE: DO YOU HAVE ANY MONEY IN BANK OR OTHER INSTITUTION? DO YOU OWN STOCKS, BONDS, PERSONAL PROPERTY? DO YOU OWN REAL ESTATE? DESCRIPTION, LOCATION, VALUE: EDUCATION NUMBER OF YEARS COMPLETED: WHAT SCHOOL: HAVE YOU ANY VOCATIONAL OR TECHNICAL TRAINING? WHERE? ARMED FORCES LENGTH OF SERVICE: TYPE OF DISCHARGE: ADULT CRIMINAL RECORD HAVE YOU ANY PRIOR CRIMINAL RECORD: DATE AND PLACE OF ARREST: CHARGE AND DISPOSITION: ARE YOU CURRENTLY ON PROBATION/PAROLE? YES/NO OFFICER: 3 American LegalNet, Inc. www.FormsWorkFlow.com COLLEGE: WHERE? TO BRANCH: RANK: WHAT COUNTY: HEALTH RECORD DO YOU HAVE A PROBLEM WITH DRUGS AND/OR ALCOHOL? ARE YOU RECEIVING COUNSELING OR TREATMENT? WHOM? HAVE YOU EVER BEEN CONFINED TO A MENTAL INSTITUTION? AND PERIOD OF CONFINEMENT: DO YOU HAVE ANY SERIOUS ILLNESSES OR DISABILITIES? IF YES, WHERE IF YES, WHERE AND BY CASE INFORMATION 1. NAMES AND ADDRESSES OF ALL WITNESSES FOR DEFENDANT: (A) (B) (C) 2. NAMES AND ADDRESSES OF ALL WITNESSES FOR PROSECUTION: (A) (B) (C) 3. NAMES AND ADDRESSES OF CO-DEFENDANTS (anyone else involved): (A) (B) (C) 4. IS THERE AN ALIBI DEFENSE? YES NO IF YES, NAMES AND ADDRESSES OF WITNESSES AND WHAT THEIR TESTIMONY WILL BE: (A) (B) (C) 4 American LegalNet, Inc. www.FormsWorkFlow.com 5. DID DEFENDANT GIVE STATEMENT TO POLICE: YES A. WAS MIRANDA WARNING GIVEN: YES NO NO B. WERE ANY THREATS, PROMISES OR COERCION USED: YES IF YES, GIVE DETAILS: NO 6. WAS DEFENDANT IDENTIFIED BY EYEWITNESSES PHYSICAL EVIDENCE, SUCH AS FINGERPRINT, ETC.: YES NO IF YES, GIVE CIRCUMSTANCES UNDER WHICH IDENTIFICATION WAS MADE: 7. IF A BENCH WARRANT HAS BEEN ISSUED FOR FAILURE TO APPEAR, PLEASE STATE REASON WHY YOU DID NOT ATTEND HEARING. 8. FURTHER COMMENTS: 5 American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, petitioner prays: That the OFFICE OF THE PUBLIC DEFENDER of Washington County, Pennsylvania represents me in the above criminal cause of action without fee or cost to me as defendant. If I should become employed or my financial situation changes at any time prior to my trial, I am aware that I must notify the OFFICE OF THE PUBLIC DEFENDER as to such change. I am willing to accept the services of any lawyer in the OFFICE OF THE PUBLIC DEFENDER who is assigned to handle my case. X SIGNATURE OF DEFENDANT COMMONWEALTH OF PENNSYLVANIA COUNTY OF WASHINGTON } } } The undersigned, being duly sworn according to law, deposes and says upon his/her oath, that: 1. 2. I am the petitioner in the above-entitled action. I have read the foregoing petition and know the contents thereof, and the same are true to my knowledge, as to matters therein stated to be alleged as to persons other than my self, and, as to those matters I believe to be true. 3. This affidavit is made to inform the Court as to my status of indigency and to induce the Court to assign counsel to me as an indigent for my defense against the criminal charges that have been made against me. 4. In making this affidavit, I am aware that perjury is a felony and that the punishment is a fine of not more than $3,000 or imprisonment for not more than seven years, or both. X SIGNATURE OF DEFENDANT 6 American LegalNet, Inc. www.FormsWorkFlow.com