INSTRUCTIONS FOR PUBLIC DEFENDER APPLICANTS (18 years of age and older)

Transcription

1 INSTRUCTIONS FOR PUBLIC DEFENDER APPLICANTS (18 years of age and older) I. The application must be completely filled out. It un not be mailed or faxed into the office unless it is from a prison or a detention facility. 2. The applications will only be accepted between 9:00 a.m. to 11:00 a.m. and 1:00 p.m. to 3:00 p.m. in the Public Defender's Office 3. If you are incarcerated, you MUST provide your home address, not the prison. 4. The application MUST be signed where indicated. Your application will not be accepted unless it is completed and signed. 5. An applicant is eligible for Public Defender representation if, and only if, he or she is indigent and as a result, cannot afford to hire an attorney to represent him or her. Indigency is determined by a number of factors, including, but not limited to, income, assets and liabilities, nature of charges, and federal poverty guidelines. 6. As part of the application process, all applicants shall be required to submit the following information: o Driver's License or Photo Identification o Criminal Complaint and Affidavit o Prior years Federal Income Tax Return o Pay stubs for last three weeks o Current social security or unemployment statements o Current welfare statements (food stamp or cash assistance) o Property tax for any and all property owned o Balance of mortgage on property o Car payment bill o If married, Federal Income tax for spouse o Letter stating rmaneial support for those stating no income and a copy of the photo ID from the person providing rmancial support o Current rmancial information as requested * 1f financial information cannot be provided, you must provide a reason for your inability to provide this information. 7. application for Public Defender shall be approved unless and until the requested financial information is provided. 8. The Public Defender shall re-examine eligibility as deemed necessary. 9. If there are any changes in your financial circumstances, you are obligated to notity the Public Defender's Office immediately. Failure to do so can result in termination of Public Defender representation. Date: Applicant Name

2 Applicant: Name: Luzerne County Application for Public Defender 20 N. Pennsylvania Ave. Wilkes-Barre, P A Telepbone: (570) 825- I 754 Fax: (570) 825- I 846 Office Hours: 8:30 3.m. - 4:00p.m. Age: DOB: Driver's License #: Social Security #: Address: _--:-=:----::-- ---::-=:---;;::--_;-:- -;::;:--., :=:--:::-:-:- (Street) (CitylBorough) (State) (Zip Code) Home phone: Cell phone: Citizen of the USA? Ifnot what county: Provide a secondary contact person or pbone number Name: Address: interpreter needed (type): Relation: Phone number: Hearing information: (Provide all hearing dates and most current) Magistrate! Judge: ~. Address: Date of hearing. Time: Related People to the Case: Arresting Officer: Police Department: Co-Defendants: Witness: Victim: Date: Assigned to: OTN: CRnumber: Hearing: For Office Use Only Criminal Charges: ~.. 1

3 Employment: o Where? o Wages: $ per houf hours a week ($ salary) o Unemployment Compensation _ o Workmen's compensation _ o SSI _ o SSD _ o Public Assistance: o Medical o Food Stamps _ o Cash _ INCOME last 12 months (1 year): Combine INCOME (selflspouse) last 12 months (I year): Financial Information: AssetslIDcome Bank Account(s): 0 Checking Amount 0 Savings Amount 0 N!A HouselProperty? 1. Tax assessor value $ Checked by: 2. Mortgage $ to Other property! Assets! Automobile? J. Year and make: 2. lowe $ to 3. Address of property owned_.. 4, Tax assessor value $ Checked by: 5. Mortgage $ to If you have no income, who is supporting you? Name: Relation: Address: Phone Number: 2

4 Single Married Name ofyout spouse? ~ Does your spouse work? Who is their employer? ~ Is your spouse collecting: Unemployment Compensation Workmen's compensation SSI SSD Spouse's NET income in the past 12 months (I year): $ Separated or Divorced When was the last time you lived with yout spouse? Children Under 18? (Give names, age, and address of each child) l. 3, 2, 4,. 6,. Do you pay support? If so, how much? $._ a month Do you receive support or SSI? Is so, how much? $ a month Bail Status: I am currently in jail Bail is $ Criminal History: Bail has been posted by (name and address) Have you ever been charged with another crime? WIlen: WIlo represented you Charges: ~ Sentence: Military Background: Active Retired N/A Brmch of Service: Rank: Service Dates from:.._10: Discharge type: 3

5 STATEMENT OF APPLICANT AND PETITION TO APPOINT AN ATTORNEY I,, hereby verify that the facts 1 have set forth in the above Application for a Public Defender are true and correct to the best of my knowledge, infonnation and belief I understand that the statements herein are made subject to the penalties of I 8 Pa. C.s.A. Section 4904 relating to unsworn falsification to authorities. Date Defendant Rev