Public Defender Application Form - Elk County Page 2
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2(b) Debts (Money you owe)
$__________________________________
Mortgage (total owed)
$__________________________________
Loans: _____________________________________________
_____________________________________________________
$__________________________________
TOTAL DEBTS
$__________________________________
(c) Income (any money you receive)
Present Employer ______________________________________________________________________________________
Address: ____________________________________City_________________________State__________Zip____________
Salary: (specify per hour, week, month, etc.) $______________________ (Gross Pay) $______________________(Net Pay)
Other income in same household? ____________________
Yes or No
If Yes, specify:
Name ___________________________________________________________ Relationship _________________________
Employer _____________________________________________________________________________________________
Salary: (specify per hour, week, month, etc.) $______________________ (Gross Pay) $______________________(Net Pay)
(d) Other means of income: (specify per hour, week, month, etc.)
Assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per ______________
Worker’s Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per _____________
Social Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per ______________
Unemployment Compensation . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per ______________
Pension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per ______________
VA Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$________________________ per ______________
Other (explain) ________________________________________
$________________________ per ______________
TOTAL MONTHLY INCOME
$___________________________
(e) Expenses (per month)
Rent or mortgage payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$___________________________
Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$___________________________
Utilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$___________________________
Other (explain)______________________________________________________
__________________________________________________________________
$___________________________
TOTAL MONTHLY EXPENSES
$___________________________
1. I have read the foregoing application and know the contents thereof and the same are true to my own knowledge, except as to
matters therein stated to be alleged as to persons other than myself, and, as to those matters I believe to be true.
2. In making this affidavit I am aware that perjury is a felony and that the punishment is a fine of not more than $3,000.00 or
imprisonment for not more than seven years or both.
3. IN THE EVENT I AM ACCEPTED BY THE PUBLIC DEFENDER’S OFFICE I HEREBY AUTHORIZE THE PUBLIC
DEFENDER TO CONTINUE MY PRELIMINARY HEARING AT ANY TIME AND TO RESCHEDULE IT AT SUCH TIME
AS HE DEEMS APPROPRIATE AND MOST EFFICIENT.
4. I ALSO HEREBY AGREE TO NOTIFY THE PUBLIC DEFENDER’S OFFICE OF ANY CHANGES IN MY FINANCIAL
STATUS, ADDRESS, PHONE NUMBER, ETC.
5. I have been advised that it is the statutory duty of the Public Defender to file suit in the name of the County against me for
reasonable Attorney Fees if I have made material misrepresentations as to my assets.
___________________________________________
Signature
ORDER OF COURT
AND NOW, this _______________ day of ____________________, 20_____, the request of the defendant for counsel without fee
is allowed. ___________________________________________, Esq., is appointed as a special Public Defender.
BY THE COURT:
__________________________________
JUDGE
( ) Approved
( ) Disapproved
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