IN THE STATE COURT OF BIBB COUNTY

STATE OF GEORGIA

STATE OF GEORGIA
v.

ACCUSATION NO.:

Name

CHARGE(S):

APPLICATION FOR APPOINTMENT OF COUNSEL AND

CERTIFICATE OF FINANCIAL RESOURCES

I am the defendant in this case. I am charged with the misdemeanor offense(s) listed above. I cannot afford to hire a lawyer to assist me. I want the Court to provide me with a lawyer. I understand that I am providing the information in this declaration so the Court can evaluate my eligibility for a court-appointed lawyer, paid by Macon-Bibb County, to defend me on these charges.

1. Name:

Birthdate:

Please enter a valid value

Age:

Telephone No.:

Please enter a valid value

Email Address:

Please enter a valid value

Mailing address:

Please enter a valid value

City:

Zip Code:

2. Highest grade in school completed:

3. If employed, employer is

Net take home pay is (gross minus state, federal and social security taxes):

Weekly:

or Bi-Weekly:

or Monthly:

4. If unemployed, how long?

List other sources of income such as unemployment compensation, welfare or disability income and the amounts received per week or month:

5. Are you married?

Is your spouse employed?

6. Number of your children living with you:

Ages:

7. Do you have dependents (other than spouse or children) living with you?

Provide their names, relationship, and the amount you pay to support them:

8. Do you pay child support under a Court order?

If so, how much per month:

9. Do you own a motor vehicle? Year and model

10. Do you own a home?

Value:

How much do you owe on it?

11. Amount of house payment or rent payment each month?

12. List checking or savings accounts or other deposits with any bank or financial institution and the amount of deposits:

13. List other assets or property including real estate, jewelry, notes, bonds or stocks:

14. List indebtedness and amount of payments:

15. List any extraordinary living expenses and amount (such as regularly occurring medical expenses):

16. Do you understand that the Court may require you to reimburse Macon-Bibb County for your attorney’s fees?

I have read (had read to me) the above question and answers, and I swear the information given herein is true and correct. I understand that a false answer to any item may result in a charge of perjury. I understand by signing or typing my name below, I am so swearing.

Date:

Date is required.

Signature is required.

IN THE STATE COURT OF BIBB COUNTY

STATE OF GEORGIA

DEFENDANT’S SIGNATURE or TYPED NAME