APPLICATION FOR THE SERVICES OF A PUBLIC DEFENDER

CONTACT PERSON
Is there someone we may contact if you are unavailable? *

No Yes
Name:
Relationship:
Spouse, Mother, Father, Sibling, Grandparent, Cousin, Friend, Associate, Girlfriend, Boyfriend, Parent of Your Child, Co-Worker, etc.
Address

Street Address

Street Address Line 2

City State

Zip Code
Email

Confirmation Email For example, johndoe@gmail.com
Phone Number

Marital Status
What is your marital status?

Common Law Divorced Legally Married Separated Single Widowed

INFORMATION ABOUT YOUR SPOUSE
Name of Spouse *

First Name Middle Name Last Name Suffix
Phone Number
Email:

Confirmation Email For example, johndoe@gmail.com
Is your spouse employed? *

No Yes
If Yes, name of Employer:
Net Amount of Wages:
Per:

hour day week month

CURRENT EMPLOYER
Are you currently working (employed)? *

No Yes
Name of Employer:
Position/Title:
Physical Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number
Length of Time:
List the number of years, months days
Supervisor:
INCOME
Wages Per Hour
Wages Per Day
NET Per Week
NET Wages Per Month

EMPLOYMENT HISTORY
Do you receive unemployment benefits? *

No Yes
How long have you been unemployed?
List the number of years, months, days
If yes, how much ($) per month?
Name of Last Employer:
Address of Last Employer

Street Address

Street Address Line 2

City State

Zip Code

INFORMATION ABOUT YOUR CHARGE (S):
LIST YOUR CHARGES: *
Arrest Date

Month Day Year
Date
Do you have any documents to upload relevant to your bond, jail release, or next court date, etc.? If so, please upload your documents.

Browse Files

Cancel of
If you are using a smart phone or tablet, you may take a photo of your bond, jail release, or next court date documents to submit to our office.
Type of Bond:

Cash Property Bond (Lien) Surety/Commercial (Bail Bondsman) Release on Own Recognizance (ROR)
Bail amount: $
Amount Paid: $

INFORMATION ABOUT YOUR BAIL
Did someone post bail for you? *

No Yes
Name *

First Name Last Name
Relationship: *
Mother, Father, Brother, Sister, Grandparent, Cousin, Friend, Partner, etc.
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number
Email

Confirmation Email For example, johndoe@gmail.com

ABILITY TO PAY FOR A LAWYER
Will you or your friends/relatives hire a lawyer for the applicant (you)? *

No Yes
If yes, who is willing to help pay?
Address

Street Address

Street Address Line 2

City State

Zip Code
Telephone Number
Email

Confirmation Email For example, johndoe@gmail.com
How much are you willing to pay for a lawyer? ($)
per

SWORN STATEMENT OF INDIGENCY AND RESPONSIBILITY FOR A REIMBURSEMENT: I hereby affirm that the above statements are true. I am unable to hire a lawyer because of lack of funds. I am applying for services from the Public Defender Office. I understand that to the extent that I 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: I 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.

ELECTRONIC SIGNATURE AGREEMENT: By typing and digitally signing my name below, I agree it constitutes my digital signature and is the legally binding equivalent to my manual signature. Today, I certify that the information I am digitally submitting on pages 1-13 of this application are true and correct to the best of my knowledge, information, and belief. Further, I agree that the use of a key pad, mouse, trackpad or other device to select an item, button, icon, or similar act/action, or to otherwise provide to the 40th Judicial District Public Defender office or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes my signature (hereafter referred to as “E-Signature”), acceptance and agreement as if actually signed by me in writing. I agree to notify the District Defender for the 40th Judicial District immediately upon discovering that any of the information contained in this online application is not true and correct as of the date of this application.
Name (type): *
Applicant's E-Signature: *

Clear
Date: *

Month Day Year
Date
2020 Application for Services of the Public Defender

40th Judicial District Public Defender Office | St. John the Baptist Parish

www.stjohnpdo.org
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STATE OF LOUISIANA

APPLICATION

APPLICANT INFORMATION

CONTACT PERSON

Marital Status

INFORMATION ABOUT YOUR SPOUSE

CURRENT EMPLOYER

INCOME

EMPLOYMENT HISTORY

GOVERNMENT ASSISTANCE

ADDITIONAL INFORMATION ABOUT YOUR HOUSEHOLD

INFORMATION ABOUT YOUR CHARGE (S):

INFORMATION ABOUT YOUR BAIL

ABILITY TO PAY FOR A LAWYER