APPLICATION FOR PUBLIC DEFENDER SERVICES - Juvenile 400-00358J Application for Public Defender Juvenile (0/201) Page 1 of 2 State of Vermont Vermont Superior Court Division Unit Type of Case Docket Number FAMILY Name First Last Name of Juvenile Other Family Members Living with You (adults, child(ren)) Mailing Address Town/City State Zip Telephone Number Date of Birth Social Security Number Total Number of Family Members in Household (including y ourself) EMPLOYMENT Are you employed? Yes No address(es) Hourly rate of pay $ Hours worked per week Employer(s) Name(s) and Address(es): INCOME EXPENSES Yes No If all adults living with you receive public assistance, it is not necessary to fill out the Expenses section below. Otherwise, enter your monthly household expenses . Do you receive Public Assistance? ( TANF/Reach UP; SSI , General Assistance) A ny f amily m embers l iving with y ou r eceive a ssistance? Current Monthly Income Rent or Mortgage P ayment $ You Other Family Household Members Living with You Electric Service Phone $ $ Gross Income from Wages $ $ Fuel (heat and/or gas) $ Self - Employment/Business Income (other than wages) $ $ F ood $ Unemployment Compensation $ $ Clothing $ Child Support $ $ Medical $ Public Assistance $ $ Child Support $ Other Income (Including Disability Insurance and Social Security) $ $ Auto Loan Payments $ Total Income $ $ Property Taxes $ Total Monthly Income (Your income plus family household members) $ Insurance (include Health, Auto, etc.) $ Total Income in the past 12 months $ Other Expenses $ Is your income in the last 30 days significantly different from your monthly income during the previous year ? Yes No If YES, please explain the circumstances on the next page. T otal Expenses $ Cash Assets Other Assets Real Estate (Location) Auto (Make, Model, Y ea r) Cash On Hand $ Checking Account $ Fair Market Value $ $ Savings Account $ Outstanding Mortgage/Loan $ $ Total Cash Assets $ Net Value $ $ NOTICE: You may be ordered to pay a minimum fee towards the cost of your legal services even if you are receiving public assistance. You may ask the Court to reduce the amount you are ordered to pay. Additional Assets : I h ave additional assets: Yes No If Yes, describe them below Vehicles Make, Model, Year Fair Market Value (FMV) Amount Owed Net V alue $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR PUBLIC DEFENDER SERVICES - Juvenile 400-00358J Application for Public Defender Juvenile (0/201) Page 2 of 2 Real Property Description Fair Market Value (FMV) Mortgage Net Value $ $ $ $ $ $ Other Assets ( tools, equipment, recreational vehicles, electronics, stocks, bonds, etc. ) Description Fair Market Value (FMV) Use additional sheets as necessary. $ $ Other Employed Family Household Members Name of Family Member Name of Employer Change in Monthly Income: income and the reasons why it changed. My income last year (past 12 months) was: $ The income from other family household members last year was: $ The reason for the change is: (This section must be filled out if you have a change in income) I request the Court assign a lawyer to represent me in th case because of my low income. I further ask that all necessary costsand expenses for legal service, as allowed by the court, be paid by the State of Vermont. I make the above answers UNDER PENALTY OF PERJURY. Signed and sworn before me: Notary Public Date Applicant Signature Date Determination of Financial Eligibility Applicant is not a financially need y person in that applicant has sufficient income to retain private counsel and/or has sufficient liquid or non - liquid asset s which could provide collateral to borrow funds to retain private counsel. Applicant is a financially needy person in that applicant does not have sufficient income to retain private counsel and does not have sufficient liquid or non - liquid assets which could provide collateral to borrow funds to retain private counsel. Minimum Payment: under 125% of poverty. Applicant is ORDER ED to pay the minimum payment of $50 within 60 days unless this fee is waived by the Court. above 125% of poverty an d applicant has income and assets available to support an immediate copayment to cover a part of the cost of services . Applicant shall pay $ to the Clerk of the Court . above 125% of poverty and applicant has income and assets available to reimburse the state for the cost of services. Applicant shall pay $ to the Clerk of the Court within 60 days of the date of this Order . NOTICE : If Public Defender Assessment and reimbursement is not fully paid within 60 days, any amount still due will be sent to the Tax Department for offset and collection agency. Signature of Clerk or Designee Date Findings and Order The Co urt has reviewed the Petition and Affidavit and finds that: The interests of justice require representation of the Juvenile . The interests of justice require representation of the Applicant. The interests of justice do NOT require representation of the Applicant. It is hereby ORDERED: Counsel ASSIGNED to Juvenile. Counsel ASSIGNED to Applicant in that applicant is financially needy and the interests of justice so require. Counsel DENIED to Applicant . Signature of Judge Date Notice of Right to Appeal: You have the right to appeal this Order to the Judge of this Court. Your appeal must be in writing with the Clerk of this Court within 7 days of the date of this Order . . American LegalNet, Inc. www.FormsWorkFlow.com