40th Judicial District Application for Services

40th JUDICIAL PUBLIC DEFENDER OFFICE APPLICATION FOR THE SERVICES

Information obtained hereby may be revealed to the Court to assist in determining whether and how much the applicant should be required to contribute to the costs of the services provided. After a judge makes a preliminary determination of indigency, the court shall require that an application be made for defense services to be provided by the public defenders. Statements regarding indigency shall be under oath. This form is used by the District Public Defender to determine the nature and extent of the financial resources available for obtaining representation and this information may be made known to the court.
Type a question*

I paid the $40.00 application fee.I did not pay the $40.00 application fee. (Note: If you have not paid your $40.00 application fee, please make arrangements to pay your fee. Fees may be paid on our website: www.stjohnpdo.org)
Applicant's Name*
Juvenile Client's name
SSN (required)*
Date of Birth*

MonthDayYear
Date
Highest Grade Completed
Home
Work
Cell*
Email Address (required)*
example@example.com
How many people live in your household?
Ethnicity (optional):

AsianBlackHispanicNative AmericanWhite
United States Veteran?

NoYes
Marital Status:

DivorcedMarriedLegally SeparatedSingle
Mailing Address*
Who Posted Bail?
Relationship
Name of Current Employer
Income
Income

HourlyWeeklyMonthly
Are you unemployed?*

NoYes
How long have you been unemployed?
Do you receive unemployment benefits?

NoYes
If yes, how much per month?
Do you have any health issues affecting your ability to work?

NoYes
Has documentation affecting ability to work been provided?

NoYes
Are you receiving Governmental Assistance?

YesNo
What kind (type) ?
How much?
Did the applicant provide documentation of government assistance?

NoYes
What is the amount of your monthly obligations?
Do you own or have an economic interest in any of the following assets? (check all that may apply_

CashLandArtwork/JewelryCheckings/Savings AccountRV, Boat or MotorcycleFirearmCarUS/LA Tax RefundStocks/BondsHomeCDLivestock
SWORN STATEMENT OF INDIGENCY AND RESPONSIBILITY FOR REIMBURSEMENT: I hereby affirm that the above statements are true. am unable to hire a lawyer because of lack of funds. I am applying for services from the Public Defender Office. lunderstand that to the extent that may be financially able to pay for an attorney and other necessary services and facilities of representation, the court may order me to pay for these items in installments, or in any other manner which it believes reasonable and compatible with my financial ability.

AUTHORIZATION FOR RELEASE OF RECORDS PERTAINING TO AND/OR NAMING ME: hereby authorize the United States Internal Revenue Service, the Social Security Administration, the Louisiana Department of Revenue and Taxation, any public Housing Authority, and every bank to whom this document is presented, to release copies of records of all income, taxes, refunds, deposits, and earnings, to the representative of the 40th Judicial District Public Defender Office, for the purpose of proving or disproving the truthfulness of any of my statements herein.
Applicant*
Date*

MonthDayYear
Date
Should be Empty: