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If you DO NOT desire the services of court appointed counsel, please sign and date here:

Signature: __________________________________

Date:____________________________________________

BOND INFORMATION: Total Bond Amount: $__________________ Who posted your bond? ____________________________

Address/phone number for bondsperson: __________________________________________________________________________

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 may also be imposed by the court at sentencing.

VERIFICATION AND 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.

This Application is for _______ case(s). I understand that I will be assessed an application fee and any applicable attorney fees

for each case.

I HEREY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST

OF MY KNOWLEDGE.

This _____ day of _____________________, 20_____.

SIGNATURE: __________________________________

Print Name:

____________________________________

ASSISTANCE: The understated person provided

assistance to the defendant/child with the completion of

this form due the defendant’s inability to read and write.

Name:

_______________________________________

Phone:

______________________________________

Address: _______________________________________

Interviewer Name: ______________________________ (Print Name)

(rev. 06/2012)

Standart Council Application For Public Defender Services Form - Georgia Public Defender Page 2

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