Weekend House Counsel C.A.A. Form

Ticket/Case Number

First Name

Middle Initial

Last Name

Address, city, state and zip code

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email address

The defendant requests the appointment of an attorney and submits the following information:

Check all that apply

Charge

Type of charge

Next Hearing Date

Date

Bail Amount

Bond Posted. Check for yes.

Residence

Marital Status

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

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

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

House Counsel Signature

Please verify that you are human

COURT APPOINTED ATTORNEY