Application For Public Defender Services

Case Information

Application Date:

Date of Arrest:

Date of Offense:

In Jail:

County:

Court:

Court Date:

Case Number(s):

Charges:

CO-DEFENDANTS:

Last Name:

First Name:

Middle Name:

Other Names(s):

Address:

City:

State:

Zip:

Date of Birth:

Social Security Number:

Race:

Sex:

Telephone No(s):

Home:

Cell:

Work:

The person who can always reach you:

Name:

Telephone:

Address:

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Marital Status

Marital Status:

Spouse's Name

Is your spouse employed

Yes

No

N/A

If yes, Where?

Spouse’s Income:

$

/

Ages of your children who live in the house with you:

List any other dependents:

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EMPLOYMENT:

Are you employed (including self-employment, part-time work, or “odd jobs”)?

Yes

No

N/A

If yes,

Employer name:

Adddress:

Telephone Number:

Job Title:

Length of Employment:

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

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Income

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

$

/

If child support not deducted from check, state amount of child support obligation:

$

/

If incarcerated, do you have income while in jail?

Amount

$

Do you receive child support?

Amount

$

Do you receive unemployment or workers compensation?

Amount

$

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

Amount

$

Have you ever served in the U.S. Military?

If so, what branch?

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

Are you disabled?

If yes, what type of Disability:

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

If yes, who

Other payments you receive from any source

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THINGS YOU OWN:

Cash, checking accounts, savings accounts, retirement accounts, inmate accounts:

$

Motor vehicles:

Year

Model

Make

Est.Value

$

Is any real estate titled in your name?

Equity:

$

Other assets or property, other than usual and customary household furnishings. List and state est.value.

PROBATION:

Court ordered monthly payment.

$

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:

If you DO NOT desire the services of court appointed counsel, please sign and date here:

Signature:

Date:

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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 court- appointed 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 not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.

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

I consent to and acknowledge that my /my minor child/tax dependent person’s attorney may be assisted by a Registered Law Student under the Student Practice Rule of the Supreme Court of Georgia.

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

This day of , 20.

SIGNATURE:

Print 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:

Phone:

Address:

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NOTICE OF APPLICATION FEE

Georgia law requires every person who applies for legal defense services under Chapter 12 of Title 17 of the Official Code of Georgia Annotated to pay the Public Defender Office (the entity providing the services) a single fee of $50.00 for the application for, receipt of, or application for and receipt of such services. [O.C.G.A. § 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 may 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. § 15-21A-6(b)]

If you would like to request a waiver, please fill out the waiver motion form and have it notarized. You can get a waiver motion form from this office. Please note that only the trial judge is authorized to waive this fee. If the fee is not waived, then it must be paid BEFORE YOUR CASE IS CLOSED.

You may contact this office to make arrangements to pay the fee.

Your payment must be in the form of a MONEY ORDER payable to OCPD-MACON CIRCUIT. Be sure the name, address and phone number of the person we represent is on the money order.

APPLICATION FOR PUBLIC DEFENDER SERVICES

Case Information

Personal Information

Marital Status

EMPLOYMENT:

Income

THINGS YOU OWN:

PROBATION:

UNUSUAL EXPENSES:

BOND INFORMATION

NOTICE OF APPLICATION FEE

OFFICE OF THE CURCUIT PUBLIC DEFENDER – MACON CIRCUIT

ATTN: DERESA CRUZ

201 SECOND STREET, SUITE 550

MACON, GA 31201

PLEASE RETAIN YOUR RECEIPT FOR THE MONEY ORDER FOR YOUR RECORDS.

Applicant’s signature

Date