Georgia Public Defender Standards Council Application For Public Defender Services

 

Date of Arrest

Date of Offense

Were you referred by the Pretrial Diversion Division?

Yes

No

County

Court Date

Court Time

Last Name

First Name

Middle Name

Email Address

Other Name(s)

Case Number(s)

Charges

Co-Defendants

Address

City

State

Zip Code

Telephone No(s)

Primary

Cell

Work

Date of Birth

Social Security Number

Race

Sex

The person who can always reach you

Name

Telephone

Address

MARITAL STATUS

Single

Divorced

Seperated

Married

Living with the parent of your children

Spouse’s Name

Is your spouse employeed?

Yes

No

If yes, where?

Spouses income (Check one)

week

two weeks

month

year

Spouse's Income

Ages of children who live with you

List any other dependents

EMPLOYMENT: Are you employed (This includes self-employment, part-time work, or “odd jobs”)

Yes

No

Employer Name

Employer Address

Employer Phone

Job Title

Length of employment

If unemployed or employed less than one year on the job, state the date and income of your most recent prior employment.

Date

Prior Income

INCOME: Net income (total income, minus deductions required by law and child support payments deducted from paycheck)

Current Income

Choose One

week

two weeks

month

year

If child support not deducted from check, state amount: $

If incarcerated, do you have income while in jail?

Yes

No

Amount $

Do you receive child support?

Yes

No

Amount $

Do you receive unemployment or workers compensation?

Yes

No

Amount $

Do you receive: Military, VA, Social Security, SSI, TANF, Food Stamps, or Retirement benefits?

Yes

No

Benefit Amount

If you do not pay your own basic living expenses, state the relationship of the person who does.

Are you disabled? Yes / No If yes

Yes

No

what type of Disablility

Does anyone else claim you as a dependent for tax purposes?

Yes

No

If yes, who

Other payments you receive from any source. Please type N/A if none.

THINGS YOU OWN: Cash, checking accounts, savings accounts, retirement accounts, inmate accounts

Motor vehicles: State year, model and make

vehicle value

Is any real estate title in your name?

Yes

No

Equity

Other assets or property, other than usual and customary household furnishings

List Other Assets Or Property and State Value(s)

Are you required to make any court ordered payments? If so please provide the type of payment and total monthly amount.

UNUSUAL EXPENSES: Unusual expenses (other than basic living expenses). Specify type and amount.

BOND INFORMATION

Total Bond Amount

Who posted your bond

Address for bondsperson

Phone number for bondsperson

NOTICE OF APPLICATION FEE AND ATTORNEY FEE:  Georgia law requires every person who applies for legal defense services under Chapter 12 of Title 17 to pay the Public Defender Office ( the entity providing the services) a single fee of $50 for the application for, receipt of, or application for and receipt of such services (O.C.G.A. Section 15-21A 6(b).  However, this application fee may not be imposed if the payment of the fee is waived by the court in which you are appearing.  The court shall waive this fee if it finds that you are unable to pay the fee or that hardship will result if the fee is charged.  (O.C.G.A. Section 15-21A 6(b).  Attorney fees for public defender representation may also be imposed by the court at sentencing.
 
VERIFICATION AND RELEASE:  BY MY SIGNATURE BELOW, I SWEAR UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND BASED UPON MY PERSONAL KNOWLEDGE, AND I REQUEST THAT THE CIRCUIT PUBLIC DEFENDER’S OFFICE (CPD) REPRESENT ME, OR THE MINOR CHILD OR TAX-DEPENDENT PERSON I AM PARENT OR GUARDIAN OF, IN THE ABOVE STYLED CASE(S).  FURTHER, I AGREE TO IMMEDIATELY REPORT ANY CHANGE IN MY FINANCIAL SITUATION TO THE CPD OR TO THE COURT.  I HEREBY AUTHORIZE ANY PERSON OR AGENCY REQUESTED BY THE CPD OR ANY OF ITS EMPLOYEES TO RELEASE TO THE CPD ANY INFORMATION REQUESTED TO ASSIST IN CONSIDERATION OF MY APPLICATION.  INFORMATION MAY INCLUDE INFORMATION ABOUT HOUSEHOLD INCOME, EMPLOYMENT, EXPENSES, LIABILITIES, OR OTHER INFORMATION REQUESTED TO ASSESS THE APPLICATION.  I ALSO VERIFY THAT I HAVE READ THE NOTICE OF APPLICATION FEE.  I UNDERSTAND THAT IF I HAVE MADE ANY FALSE STATEMENTS THAT I MAY BE CHARGED WITH A FELONY WHICH CARRIES A PENALTY OF FROM ONE TO FIVE YEARS to wit:  § 16-10-20.  False statements and writings; concealment of facts:  A person who knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes a false, fictitious, or fraudulent statement or representation; or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of state government or of the government of any county, city, or other political subdivision of this state shall, upon conviction thereof, be punished by a fine of no more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.
 

This Application is for

casenumbers

case(s). I understand that I will be assessed an application fee and any applicable attorney fees for each case.

I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Date

Signature

Sign above

Name

ASSISTANCE: The understated person provided assistance to the Defendant/child with the completion of this form due the defendant’s inability to read and write.

Name of person providing assistance

Phone

Address