Fill and Sign the Court Appointed Form

APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM Pursuant to §21-1-103(3), C.R.S., a processing fee of $25.00 may be collected by the court upon final disposition of this case. Case number: _____________________Court Room: _________________________________________ District: ____________________________ Most serious charge: ________________________________________________ Next hearing date/Type: __________________________________ All sections must be completed. Print neatly. If an item does not apply, write N/A. Applicant Applicant’s Employer Name ____________________________________________________ Mailing Address ____________________________________________ Street Address (if different) ____________________________________ City, State, Zip _____________________________________________ Phone number _____________________________________________ Soc. Sec. No. ____________________ Birthdate __________________ Driver’s License No. ____________________ State ________________ Company _________________________________________________ Mailing Address ____________________________________________ Street Address (if different) _______________________________________ City, State, Zip _____________________________________________ Phone Number _____________________ Position _________________ Length of Employment _________________ Hours/Week ___________ Pay Dates: ______________________ Pay Rate: $_______________ Other Household Members (Spouse, Partner, Parent, etc.) Other Household Member’s Employer Name ____________________________________________________ Relation to Applicant _________________________________________ Mailing Address ____________________________________________ Street Address (if different) ___________________________________ City, Sta te, Zip _____________________________________________ Phone number _____________________________________________ Soc. Sec. No. ________________________ Birthdate ______________ Driver’s License No. ______________________ State ______________ Company _________________________________________________ Mailing Address ____________________________________________ Street Address (if different) _______________________________________ City, State, Zip _____________________________________________ Phone Number ___________________ Position __________________ Length of Employment ________________ Hours/Week ____________ Pay Dates: _______________________ Pay Rate: $_______________ Marital Status :  Single  Married  Partner in a Civil Union  Separated  Divorced/Civil Union Dissolved Total Number of Dependents (including yourself): Gross Monthly Income (See definitions on reverse for further information.) Amount Monthly Expenses (See definitions on reverse for further information.) Amount Self (wages, salary, commission) $ Rent/Mortgage $ Spouse/Partner/Other Household Members Groceries Parents (if same household) Utilities Unemployment Benefits Clothing Social Security/Retirement Funds Maintenance (Spousal/Partner Support) and/or Child Support Maintenance (Spousal/Partner Support) Medical/Dental Other Income (see Page 2) Other Expenses (identify source) Other Income (see Page 2) Other Expenses (identify source) Total Household Income $ Total Expenses $ Assets Amount Description Savings Account Balance $ Name of Bank: Checking Account Balance Name of Bank: Value of Vehicles Year and Model: Value of Recreation Vehicles Amount Owed: $ Value of House Type: Value of Other Property Type: Value of Stocks, Bonds, Mutual Funds Type: Value of Other Investments Year and Model: Total Assets $ Convertible to Cash = $ References: 1. Name/Address/Phone ____________________________________________________________________________________ 2. Name/Address/Phone ____________________________________________________________________________________ Guidelines:  At or below or  Above or  Automatically eligible for PD/GAL/RPC (  In custody &/or bond allowed  Out on bond) or  Refer to scoring instrument (Criminal, Misdemeanor, Traffic, Juvenile Delinquency cases) Signature of investigator/clerk/PD: ________________________________________ Date: ___________________________ I swear under penalty of perjury that the above-contained information is true and complete. I also understand that if the court grants this request, I may later be ordered to reimburse the State of Colorado for attorney fees spent on my behalf. Client signature ____________________________________________________ Date: __________________________ Signature of judicial officer: ____________________________________________ Date: ___________________________ Request:  granted or  denied JDF 208 R10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM Page 1 of 2 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM General Information It is important that you accurately complete all sections of this form as appropriate based on your personal circumstances. If a section does not apply, please write N/A. A. Gross Monthly Income. Includes income from all members of the household who contribute monetarily to the common support of the household.  Income categories to include: Wages, including tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI), Workman’s Compensation Benefits, and alimony. Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the applicant’s income in a fashion which would allow the applicant proprietary rights to the roommate’s income.  Income categories do not include: TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned from a disability, child support payments, or other public assistance programs. B. Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity, and personal property or investments which could readily be converted into cash without jeopardizing the applicant’s ability to maintain home and employment. C. Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 208. If you are applying to have your filing fee waived, you may be asked to supply:  Copies of the previous three months’ bank statements, including checking and savings. DO NOT provide originals.  Copies of the previous three months’ pay stubs and/or proof of income must be included. DO NOT provide originals. JDF 208 R10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM Page 2 of 2