Application for Public Defender

Application for Public Defender

Confidential Indigency Screening Form
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Alternative Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- What is your marital status?*
  
  SingleSeparatedMarriedDivorcedWidowed
- Do you have any minor children?*
  
  YesNo
- Age(s)
- Are you a U.S. citizen?*
  
  YesNo
- County of Citizenship
- Are you a Veteran?*
  
  YesNo
- Branch
- Check all that apply*
  
  I am under the age of 18.I am currently serving a sentence in jail or prison.I am currently receiving residential treatment in a mental health facility.I receive public assistance (SSI, SSDI, Food Stamps, Medicaid, Section 8, etc).I am homeless.None of the above.
- Are you currently employed?*
  
  YesNo
- Type of employment*
  
  Full-timePart-timeSeasonalSelf-employedUnemployed
- Where do you work?*
  Enter N/A if you are currently unemployed.
- What is your monthly income? *
  Enter N/A if you are currently unemployed.
- What type of case are you facing?*
  
  Felony CriminalMisdemeanor CriminalTrafficPPO ViolationProbation ViolationBond Violation/Contempt/Show Cause
- Do you have an active warrant?*
  
  YesNo
- Are you on bond?*
  
  YesNo
- Do you have other pending cases?*
  
  YesNo
- Are you currently on probation or parole?*
  
  YesNo
- Have you ever been convicted of a felony?*
  
  YesNo
- Case Number*
- Judge:*
- Next Court Date*
  
  MonthDayYear
- Electronic Signature Agreement
  
  By checking the "I agree" box below, you agree and acknowledge that (1) your answers are true and correct to the best of your knowledge, (2) submitting this form does not guarantee eligibility for court appointed counsel, (3) your application will not be signed in the sense of a traditional paper document and that by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and (4) you may still be required to provide a traditional signature and further documentation in support of your responses at a later date.
- I agree
- Signature*
- Today's Date*
  
  MonthDayYear
- Please verify that you are human*
- Should be Empty: