Fill and Sign the Court Appointed Attorneys Public Defendersanoka Form

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 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. ApplicantApplicant’s EmployerName ____________________________________________________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, 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: $_______________Marital Status: Single Married Partner in a Civil Union Separated Divorced/Civil Union Dissolved Total Number of Dependents (including yourself):Gross Monthly Income (See definitions on reverse for further information.)AmountMonthly Expenses (See definitions on reverse for further information.)AmountSelf (wages, salary, commission)$Rent/Mortgage$Spouse/Partner/Other Household MembersGroceriesParents (if same household)UtilitiesUnemployment BenefitsClothingSocial Security/Retirement FundsMaintenance (Spousal/Partner Support) and/or Child SupportMaintenance (Spousal/Partner Support)Medical/Dental Other Income (see Page 2)Other Expenses (identify source)Other Income (see Page 2)Other Expenses (identify source)Total Household Income$Total Expenses$AssetsAmountDescriptionSavings Account Balance$Name of Bank: Checking Account BalanceName of Bank: Value of VehiclesYear and Model:Value of Recreation Vehicles Amount Owed: $Value of HouseType:Value of Other Property Type:Value of Stocks, Bonds, Mutual Funds Type:Value of Other InvestmentsYear and Model:Total Assets$Convertible to Cash = $References:1. Name/Address/Phone ____________________________________________________________________________________2.Name/Address/Phone ____________________________________________________________________________________Guidelines: At or below or Above orAutomatically 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 2 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.