Public Defender Application - Pennsylvania Office Of The Public Defender Page 4
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4PLEASE READ CAREFULLY BEFORE SIGNING:
I,
, BEING DULY SWORN TO LAW, UPON MY OATH, DEPOSE
AND SAY:
1.
THAT THE FACTS CONTAINED IN THE FOREGOING APPLICATION ARE TRUE AND
CORRECT.
2.
THAT THE SAID ALLEGED CRIME(S) DID OCCUR IN NORTHAMPTON COUNTY IN
THE COMMONWEALTH OF PENNSYLVANIA.
3.
THAT I HAVE NOT KNOWINGLY CONCEALED, OR IN ANY WAY MISREPRESENTED
MY FINANCIAL RESOURCES.
4.
THAT I AM INDIGENT AND UNABLE TO PROCURE SUFFICIENT FUNDS TO OBTAIN
LEGAL COUNSEL TO REPRESENT ME.
5.
THAT I AUTHORIZE MY EMPLOYER, BANK, OR ANY ENTITY MAKING PAYMENTS
TO MYSELF OR TO MY SPOUSE TO RELEASE INFORMATION CONCERNING THE
AMOUNT AND NATURE OF SAID PAYMENTS TO THE PUBLIC DEFENDER’S OFFICE.
THAT IF THE PUBLIC DEFENDER’S OFFICE ACCEPTS MY CASE, I WILL NOTIFY THE
6.
OFFICE OF ANY CHANGE IN MY FINANCIAL RESOURCES; INCLUDING RELEASE ON
BAIL, EMPLOYMENT, CASH INCOME, OR ANY OTHER OF THE ITEMS LISTED IN THIS
APPLICATION.
7.
THAT I AM AWARE THAT I CAN BE PROSECUTED FOR PERJURY IF I HAVE MADE
ANY FALSE STATEMENTS, MISREPRESENTATION OR CONCEALMENT.
8.
THAT I CAN BE PROSECUTED FOR THEFT IF I OBTAIN THE SERVICES OF A PUBLIC
DEFENDER BY MEANS OF FALSE STATEMENT, MISREPRESENTATION, OR
CONCEALMENT.
9.
THAT I CAN BE PROSECUTED IF I CONTINUE TO ACCEPT SUCH SERVICES AFTER
MY FINANCIAL CONDITION HAS MATERIALLY CHANGED WITHOUT NOTIFYING
THE PUBLIC DEFENDER’S OFFICE.
10. THAT IN ANY SUCH CASE, THIS APPLICATION MAY BE USED AS EVIDENCE
AGAINST ME.
SIGNATURE OF APPLICANT
VERIFICATION:
I VERIFY THAT THE STATEMENTS MADE IN THIS AFFIDAVIT ARE TRUE AND
CORRECT. I UNDERSTAND THAT FALSE STATEMENTS MADE HEREIN ARE SUBJECT TO THE
PENALTIES OF 18 Pa.C.S.A. §4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES
SIGNATURE OF APPLICANT
DATE OF APPLICATION
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