Application for a State Paid Professional

Application for a State Paid Professional

JDF 208
County*
Division
Case Number
21M100 / 21T100 / 21CR100 / 21JD100 / etc.
Courtroom
Because I (or they) can’t afford one, I would like the court to provide a state paid:*

LawyerGuardian ad litemCourt VisitorChild & Family Investigator
For*

Me/My CaseAnother Party (fill in their information below)
Please note for this form:
- You must fill in all blanks. Write “No” or “None” if a blank doesn’t apply.
- The court may charge a $25 processing fee at the end of the case.
- You/They may have to repay the state for the professional’s fees.
Basic Information
Name*
Birthday

MonthDayYear
Mailing Address
Street Address (if different)
City, State, Zip
Phone Number
Email
Work Information
Job Title
Company
Address

Work Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Work Phone
Length of Employment
Pay Date(s)
Once a week, every two, every month, etc.
Hours/Week
An average or range.
Pay Rate
Case Information
Next Hearing Type
First Appearance / Pre-Trial Conference / etc.
Next Hearing Date

MonthDayYear
Most Serious Charge:
Household Information
Status*

SingleMarried or Civil Union PartneredSeparatedDivorced
Number of Dependents (including yourself)*

Please List Household Members

	Name	Relationship	Income Before Taxes
Person 1
Person 2
Person 3
Person 4

Note - Household members (for the above table and below income section) does not include roommates. It means those who contribute income to the common support of the home and you share bank accounts or commingle funds with them.
Monthly Income
Note - Do not include food stamps, public assistance, subsidized housing, child support, TANF payments, or veteran's disability income.

Do include wages, tips, salaries, bonuses, royalties, annuities, dividends, comissions, capital gains, severance pay, trust income, retirement benefits, independent contractor pay, social security disability (SSD), social security supplemental income (SSI), and worker's compensation benefits.
Yours (wages/salary/commission/tips)*
Household Members
Only those who contribute to the common support of the home.
Parents (if same household)
Unemployment Benefits
Social Security/Retirement
Maintenance (alimony)
Other 1 - Type
Other 1 - Amount
Other 2 - Type
Other 2 - Amount
Total Household Income
Automatically calculated from the above information.
Proof of Income
You may have to provide the three previous month’s bank statements and proof of income, our admins can review this application to determine if it is required. Generally it is though, so if you do have paystubs or other proof of income on hand you can attach it or add a picture of it here.
Cancelof
Monthly Expenses
Note - Do not include nonessential items such as cable, streaming services, club memberships, entertainment, dining out, alcohol, cigaretts, etc.
Rent/Mortgage
Groceries
Utilities
Clothing
Maintenance/Child Support
Medical/Dental
Transportation
Loans/Credit Cards
Total Expenses
Automatically calculated from the above information.
Assets / What is Owned
Savings Account

Value

Bank Name

CityState / Province

Postal / Zip Code
Checking Account

Value

Bank Name

CityState / Province

Postal / Zip Code
Vehicle 1

Value

Year & Model

Any amount you still owe.State / Province

Postal / Zip Code
Vehicle 2

Value

Year & Model

Any amount you still owe.State / Province

Postal / Zip Code
House

Value

Type

Any amount you still owe.State / Province

Postal / Zip Code
Other Property

Value

Type

Any amount you still owe.State / Province

Postal / Zip Code
Stocks, Bonds, and Mutual Funds

Value

Type

CityState / Province

Postal / Zip Code
Other Investments

Value

Type

Any amount you still owe.State / Province

Postal / Zip Code
Total Assets
Automatically calculated from the above information.
How much of your total assets would you say is readily convertible to cash?
Only that which could be converted without risking your ability to maintain a home and employment.
References

These are people who we can reach out to if we cannot get ahold of you by the contact info you leave. This does not operate as permission to speak with these people about any details of your case.
Person 1

Name

Phone

EmailState / Province

Postal / Zip Code
Person 2

Name

Phone

EmailState / Province

Postal / Zip Code
Sign & Date
I swear that the information contained above is true and complete.
Print Your Name*
Your Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Application for a State Paid Professional

Basic Information

Work Information

Case Information

Household Information

Monthly Income

Proof of Income

Monthly Expenses

Assets / What is Owned

References

Sign & Date