COUNTY OF BLAIR PUBLIC DEFENDER

Transcription

1 COUNTY OF BLAIR PUBLIC DEFENDER 423 Allegheny Street Ste. 344 Russell J. Montgomery Hollidaysburg, PA Chief Public Defender Telephone: (814) Fax: (814) APPLICATION FOR COUNSEL All applications for representation submitted to the Public Defender s Office will require documentation of all household earned or unearned income. TYPE OF INCOME WAGES UNEMPLOYMENT COMPENSATION CHILD SUPPORT SOCIAL SECURITY SSI DISABILITY WELFARE BENEFITS RETIREMENT/ANNUITIES ACCEPTABLE DOCUMENTATION Pay Stubs Letter from Employer on Company Letterhead Statement from Domestic Relations Letter from Social Security Copy of Bank Statement Showing Direct Deposit Statement from Department of Public Welfare Retirement/Annuity Disbursement Letter APPLICATIONS SUBMITTED WITHOUT DOCUMENTATION WILL NOT BE CONSIDERED UNTIL DOCUMENT IS PROVIDED

2 APPROVED CONFLICT REJECTED TODAY'S DATE Check what type of matter you are applying for representation for and explain if necessary: New criminal charge Appeal Parole/Probation Violation PFA Contempt Costs and Fines Contempt Other (explain) My Hearing is set for (date) (time) (Courtroom) Magisterial District Judge My name is : (first) (middle) (last) My address is: (Street, Apt. No., Po Box) (City) (State) (zipcode) My telephone number is: If you cannot reach me at that number, you can leave a message at LIST THE FOLLOWING ABOUT THE CHARGES PENDING AGAINST YOU CHARGE CO-DEFENDANT VICTIM

3 My bond is set at $ I am currently in jail YES or NO Date put in jail My date of birth is / / Single Married Separated Divorced My social security number is I am an American citizen: Yes No I am presently employed: Yes No Where? My monthly income before taxes is: $ Employer's telephone number Spouse's monthly income:$ Spouse's name LIST ALL PERSONS WHO LIVE WITH YOU AND THEIR RELATIONSHIP TO YOU: NAME RELATIONSHIP HOW LONG AGE Do you pay child support? Yes No Do you receive child support? Yes No Amount paid per month $ Amount received per month$ If not employed, state source and amount of income: Public Assistance $ per month Social Security $ per month Pension $ per month Are you a veteran? Yes No SSI $ per month Unemployment $ per month Other $ per month VA Benefits $ per month

4 Do you have any of the following: Savings account: Yes No Checking account Yes No What bank and amount: What bank and amount: Do you own a house, land, mobile home, other real estate? Yes No Value $ IMPORTANT: ARE YOU CURRENTLY ON PROBATION OR PAROLE? YES NO County and State of Probation: Probationary term: Do you have a current Pennsylvania driver's license? Yes No Have you ever been charged with Driving Under the Influence? Yes No Have you ever been place on A.R.D. for driving under the influence? Yes No Have you ever pleaded guilty to Driving Under the Influence? Yes No List County and State: I give permission for your office to give information about my case to : (Name, address, and telephone) PLEASE READ CAREFULLY: I verify that the above information is true and correct to the best of my knowledge, information, and belief. This verification is made subject to the penalties of Section 4904 of the Pennsylvania Crimes Code (Pa.C.S.A. Section 4904), relating to unsworn falsification to authorities. I also agree to notify your office of any change in income or address. X (Signature)

5 FOR OFFICE USE ONLY: This application for representation by the Office of the Public Defender is hereby ACCEPTED REJECTED for the following reasons: 1. Income exceeds guidelines 2. Other DATE: Public Defender I,, having been refused the services of the Public Defender, do hereby make application to the Court of Common Pleas of Blair County and for this purpose, do hereby sign this motion that the Public Defender's decision for refusal be reviewed by the Court on this application and counsel be appointed for me. DATE: Signature of Defendant AND NOW, this day of 20, the decision of the Office of the Public Defender as set forth above is hereby AFFIRMED / OVERRULED. BY THE COURT J.