A. Personal Information First Name Middle Name Last Name Suffix Address Address 2 City/Town State/Province ZIP/Postal Code Date of Birth Email address Cell phone Home phone Alt contact B. Current Case Information Case Information Arrest Date Arraignment Date Arraignment Attorney Charges Name of Court Top Charge Felony Misdemeanor Violation Judge Next Court Date Bail: Cash Bond Pre-Trial Release ROR Remand Co-Defendants Amount of Cash or Bond $ Complainant: C. Employment Employment Status Full-time Part-time Unemployed Disabled/unable to work Student Retired Amount of Net (Take-Home) Pay: per year month bi-weekly weekly Number of dependents, if any: Occupation (if self-employed, indicate nature of business): Employer/School Address: D. Other Circumstances Are you currently incarcerated, detained, or confined to a mental health facility? Yes No Are you currently receiving need-based public assistance (or recently deemed eligible, pending receipt)? Yes No In the past six months, have you been found eligible for assigned counsel in another criminal case? Yes No E. Other Income / Assests Other Income table Pension, annuity, or retirement payments Yes No Amount: Income from real estate Yes No Amount Real estate (value /amount owed): List any other sources of income Vehicles owned (year/make/value/amount owed): Cash / Checking or Savings Bank Accounts: Retirement Accounts / IRA - Amount $ Life Insurance Cash Surrender Value $ F. Expenses expenses table Mortgage / Rent: Other Loans: Utilities Food: Car Payment / Insurance: Medication / Health Care: Child Care: Child Support Paid: Student Loan: Any other expenses: G. Hardship Factors Please describe any other hardship circumstance you request the Public Defender’s Office to consider in evaluating your application. Have you ever been convicted of a felony? Yes No If yes, what year? Did you serve time in prison? Yes No H. Applicant Signature Signature Sign above Leave this field blank
