Public Defender Application - Pennsylvania Office Of The Public Defender Page 2
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49.
Do you have any children:
No
Yes
If Yes: Name(s):
Age(s):
With whom do your children reside and address:
If your children do not live with you, are you paying support?
No
Yes
How much per week: $
To whom are your payments being made and at what address?
10. Applicant’s Employment Information
Employed at time of commitment:
No
Yes
If Yes - Where Employed:
Are you receiving any of the following payments (check all that apply):
Disability: $
Welfare: $
Workman’s Comp: $
Social Security: $
Unemployment: $
Other: (specify):
11. Spouse’s Employment Information: (Skip if not married)
Is your spouse employed?
No
Yes
If Yes, employer’s name:
Amount of take home pay:
(note if weekly, monthly, bi-weekly)
Is your spouse receiving any of the following payments (check all that apply):
Disability: $
Welfare: $
Workman’s Comp: $
Social Security: $
Unemployment: $
Other: (specify):
12. Financial Information
Do you or your spouse have any bank accounts?
No
Yes
If Yes: Where:
Checking Balance:
Savings Balace:
Do you or your spouse have any stocks/bonds of life insurance policies?
No
Yes
If Yes: Value $
Types of Funds:
Do you or your spouse own or have access to an automobile?
No
Yes
If Yes: Is the vehicle financed?
If so, monthly payment $
Do you or your spouse own any real property?
No
Yes
If Yes: Value: $
Mortgage Payment: $
Mortgage Company:
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