Weekend House Counsel C.A.A. Form

COURT APPOINTED ATTORNEY
Ticket/Case Number
First Name*
Middle Initial
Last Name*
Address, city, state and zip code*
Cell Phone Number*
Please enter a valid phone number.
Email address*
The defendant requests the appointment of an attorney and submits the following information:
Check all that apply

I am under the age of 18I am currently serving a sentence in jail or prisonI receive public assistanceI am receiving residential treatment in a mental health or substance abuse facility.
Charge
Type of charge

MisdemeanorFelonyPaternity
Next Hearing Date

MonthDayYear
Date
Bail Amount
Bond Posted. Check for yes.
Residence*

RentOwnLive with parentsRoom/BoardNo Residence
Marital Status*

SingleMarriedDivorcedSeparated
Number of dependents *
Employer name and address. If unemployed put N/A*
Length of employment. If unemployed put N/A*
Average take home pay If unemployed enter 0*
How often do you get paid. If unemployed check N/A*

weeklymonthlyevery two weeksN/A
Other income: DHHS, VA, pensions, spouse, unemployment, etc. LIST INCOME SOURCE AND AMOUNT If no other income enter 0*
List assets and value: car, home, bank deposits, inmate accounts, bonds, stocks, etc. If no assets enter 0*
Monthly Bills: Rent, installment payments, mortgage payments, child support, etc. *
I understand that a decision will be made on whether I can afford an attorney. I understand that I may be required to contribute to the cost of an attorney. I understand that I may contest my ability to pay any ordered costs if the court attempts to collect any costs for an attorney, and the court must determine whether and how much, if any amount, I would be required to pay based on my ability to pay at that time.
Date*

MonthDayYear
Date
Signature (Signed by counsel with client consent/permission.)*

Clear
House Counsel Signature*

Clear
Please verify that you are human*
Should be Empty:

COURT APPOINTED ATTORNEY