APPLICATION FEE: There is a $35 fee associated with this application. The Court may waive or reduce the fee if you cannot pay the entire fee. If the fee is not waived, the amount will be added to any costs you are ordered to reimburse at the conclusion of your case.
NOTICE: You may be required to submit verification of your Gross Income. Verification of Gross Income includes one of the following: 1) most recent pay stub reflecting current wages, or 2) most recent W-2, or 3) most recent Tax Return, or 4) Written Statement from Employer. All questions must be answered or the application will be denied, answers with zeros, slashes, or N/A are not accepted.
Separate multiple case numbers with a comma.
If you answered yes to receiving TANF, Supplemental Security Income, OR Medical Assistance for the Elderly, and have attached documentation that you personally receive such benefits, skip sections B, C, D, E, F, G and skip to section H. If you have not attached documentation showing that you personally receive such benefits, or if you answered no to receiving TANF, Supplemental Security Income, AND Medical Assistance for the Elderly, complete the entire application in order for your eligibility for indigent defense services to be determined.
You can attach documentation below before submitting your application.
MOST RECENT PAST EMPLOYMENT (LIST ALL EMPLOYERS FOR THE PAST TWO YEARS)
If you haven't had any other employers in the past 2 years, just enter 'None' in the first Employer field below.
The following is a list of different kinds of other money received. Check yes for each unearned income or other money received by yourself or spouse. Check no if not received.
For all items above checked yes, fill in the boxes below :
If you need more room, you may attach additional documents below before submitting your application.
The following is a list of assets. Check yes for each asset you or your spouse own or are purchasing. Check no if not owned or being purchased.
For all items above checked yes, fill in boxes below:
List Vehicles (car, truck, motor home, snowmobile, motorcycle, 3 wheeler, 4 wheeler, boat, or other watercraft, camper, trailer, etc.) owned , jointly owned or being purchased for yourself and/or spouse, even if the vehicle is not running or not in your possession. (if you need more room use an additional sheet of paper)
Please list the total number of persons in your home that you are financially responsible for (only people listed on your tax return). Only use initials for persons under 18.
I have answered all questions honestly and truthfully to the best of my knowledge and I am requesting that a lawyer be appointed to represent me. I understand that the information supplied on this form is not confidential. I also understand that if I have supplied false information in the application, it may lead to criminal prosecution and conviction. If counsel is appointed for me, I understand that I have a continuing responsibility to inform the court of any changes in my financial condition, employment status, or household size. I understand that even if I am found eligible to have the costs of an attorney and related expenses paid for me at this time, I may be required to pay back the attorney fees and related expenses to the State at a later time. I understand that by signing this application I give authorization for investigation into my income, assets and benefits, and this form will serve as a release of information to any source which might have such information including, but not limited to, claim information from Workforce Safety and Insurance. I agree this form will serve as a release of information to any source which might have such information, which would include Worker’s Safety and Insurance.
The following questions are optional (you do not have to answer them if you do not want to do so).