There is a $40 application fee associated with this application. The fee may be paid by credit/debit card or money order made out directly to the public defender. A fee of $2 convenience fee will be charged for credit/debit Card Transaction. If you cannot afford to pay online, the fees will still be assessed, but inabilty to pay fee, will not disqualify you from services. Do you understand?
Name
*
First Name
Last Name
Middle Name/Other Names Used
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Date of Birth
MM
DD
YYYY
Last 4 Social Security Number
Gender
*
Race
*
Are you a Veteran?
Highest Level of Education
Spoken/Written Language
Do you prefer
Case Number (If Known)
Type of Case
Date of Arrest/Summons
MM
DD
YYYY
Do you currently have a court date?
Next Court Date (If Known)
MM
DD
YYYY
Are you legally married?
Spouses Name
First Name
Last Name
Do you have any children in your custody?
Number of Children under 18 of which you have legal custody, or for whom you are paying child support
Please list ages of any children under the age of 18.
Did you file income taxes in the last 2 years
Please select the number of people who you claim as dependents (including yourself)?
None
1 dependent
2 dependents
3 or more dependents
Are you currently Employed
If No, what was you last date of employment
MM
DD
YYYY
Who is/was your current or most recent Employer?
Average number of hours worked per week?
Do you recieve any type of State or Federal Assistance?
Please list any State or Federal Assistance that you recieve. Examples- Food Stamps, Medicaid, Medicare, SSA (disability), SSI (disability), WIC, TANF, Section 8, Public Housing.
Are you currently incarcerated?
*
If Incarcerated, Where? (City/State/Facility)
Confirmation
*
Thank you!
Please don’t forget to pay the $40 application fee online by using the “Pay Application Fee ” .
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