Application for Public Defender Services
Email *
Application Date *
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Arrest Date *
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Incident Date *
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County Of Offense *
Court *
Upcoming Court Date
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Name *
Last, First Middle
Case Number(s)
Charges *
Names of Co-Defendants (people arrested with you)
Your Address (Include City, State, & Zip Code *
Home Phone Number *
Mobile Phone Number *
Work Phone Number
Date of Birth *
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Social Security Number - If not a U.S. citizen please enter 0 for value *
Race *
Sex *
Name of Contact Person *
Contact Person Address & Phone Number *
Marital Status *
Is your Spouse/Live-In Child's Parent Employed *
How often is he/she paid? *
Ages of your minor child(ren) that live with you *
List any other dependents that you claim for tax purposes
Are you employed (including self-employment, part-time work or "odd jobs"? *
If yes, Name, Address and Phone Number of Employer
Job Title
Length of Employment
If unemployed, approximately when did you last work?
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Net income (total income, minus deductions required by law and child support payments deducted from paycheck) : *
How often are you paid? *
If child support not deducted from check, state amount of child support obligation:
Child Support Due (not garnished)
If incarcerated, do you have income while in jail? *
Do you received child support? *
If yes, how much and how often?
Do you receive unemployment or workers compensation? *
If yes, how much and how often
Do you receive (check all that apply) *
Required
If you do not pay your own basic living expenses, state the relationship of the person who does.
Are you Disabled *
If yes, type of disability.
Does anyone claim you as a dependent for tax purposes *
If yes, who
Other payments from any other source
Do you have any of the following *
Required
If you have any of the above accounts, what is the value of each? *
Do you have a vehicle title to you? *
If yes, vehicle value
Is any real estate titled in your name? *
If yes, what is the address of the real estate?
How much equity do you have in your real estate?
Other assets or property, other than usual and customary household furnishings. List and state est. value:
Total amount you pay in court ordered probation fines/fees/restitution per month: *
Unusual expenses (other than basic living expenses). Specify type and amount.
Bond amount *
Who posted your bond? *
Name, Address, and Phone Number of Bondsperson. *
I am currently on (check all that apply): *
Required
If you are on probation or parole, list names of any officers to whom you report:
Are you a veteran of the US Armed Forces? *
Driver's License/State ID Number *
NOTICE OF APPLICATION FEE AND ATTORNEY FEE: Georgia law requires every person who applies for legal defense services under Chapter 12 of Title 17 to pay the Public Defender Office (the entity providing the services) a single fee of $50 for the application for, receipt of,or application for and receipt of such services (O.C.G.A. Section 15-21A 6(b). However, this application fee may not be imposed if the payment of the fee is waived by the court in which you are appearing. The court shall waive this fee if it finds that you are unable to pay the fee or that hardship will result if the fee is charged. (O.C.G.A. Section 15-21A 6(b). Attorney fees for court- appointed representation will also be imposed by the court at sentencing. VERIFICATIONAND RELEASE: BY MY SIGNATURE BELOW, I SWEAR UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND BASED UPON MY PERSONAL KNOWLEDGE, AND I REQUEST THAT THE CIRCUIT PUBLIC DEFENDER’S OFFICE (CPD) REPRESENT ME, OR THE MINOR CHILD OR TAX-DEPENDENT PERSON I AM PARENT OR GUARDIAN OF, IN THE ABOVE STYLED CASE(S). FURTHER, I AGREE TO IMMEDIATELY REPORT ANY CHANGE IN MY FINANCIAL SITUATION TO THE CPD OR TO THE COURT. I HEREBY AUTHORIZE ANY PERSON OR AGENCY REQUESTED BY THE CPD OR ANY OF ITS EMPLOYEES TO RELEASE TO THE CPD ANY INFORMATION REQUESTED TO ASSIST IN CONSIDERATION OF MY APPLICATION. INFORMATION MAY INCLUDE INFORMATION ABOUT HOUSEHOLD INCOME, EMPLOYMENT,EXPENSES, LIABILITIES, OR OTHER INFORMATION REQUESTED TO ASSESS THE APPLICATION. I ALSO VERIFY THAT I HAVE READ THE NOTICE OF APPLICATION FEE. I UNDERSTAND THAT IF I HAVE MADE ANY FALSE STATEMENTS THAT I MAY BE CHARGED WITH A FELONY WHICH CARRIES A PENALTY OF FROM ONE TO FIVE YEARS to wit: § 16-10-20. False statements and writings; concealment of facts: A person who knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes a false, fictitious, or fraudulent statement or representation; or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of state government or of the government of any county, city, or other political subdivision of this state shall, upon conviction thereof, be punished by a fine of not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both. *
For how many different arrests in this county will you need an attorney appointed? *
By typing my name below, I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. *
Type Full Name
Date *
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If assisted in completing this application due to the inability of the defendant to read or write, please list name, address and phone number of the person who assisted in completion of this application:
Dependent on Tax Returns *
Who claims you as a tax dependent? If self, enter self.
Are you covered by a health insurance policy? *
If so, who pays the premium? *
If you are not insured, type N/A.
Are you a student? *
If yes, what school do you attend?
Amount of Tuition Paid Per Semester
Amount Paid for Books
Who pays your tuition?
What kind of transportation do you have? *
Who pays for your vehicle, insurance, gasoline and maintenance and in what amount? *
Who pays for your housing and in what amount(s) *
Who pays for your meals and in what amount(s)? *
Who pays for your utilities and other living expenses and what amount(s)? *
GRANTS, SCHOLARSHIPS, ASSISTANCE, AND OTHER LOANS RECEIVED ARE AS FOLLOWS:
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