Event Calendar

Georgia Public Defender Standards Council Application For Public Defender Services

 
MARITAL STATUS
Is your spouse employeed?
Spouses income (Check one)
EMPLOYMENT: Are you employed (This includes self-employment, part-time work, or “odd jobs”)
Choose One
If incarcerated, do you have income while in jail?
Do you receive child support?
Do you receive unemployment or workers compensation?
Do you receive: Military, VA, Social Security, SSI, TANF, Food Stamps, or Retirement benefits?
Are you disabled? Yes / No If yes
Does anyone else claim you as a dependent for tax purposes?
Is any real estate title in your name?
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 public defender 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 no more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.
 

I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Sign above