Form Center

2. Application For Court Appointed Attorney

   Paulding County Public Defender

   1387 Industrial Blvd. Suite 103

   Dallas, Ga. 30132

   Office: 770.443.3463 / Fax: 770.443.9936

   Email: PDINTERN@PAULDING.GOV

   
   

   In order for this application to be processed, you will have to provide an email address in order for us to contact you, otherwise please come in person to apply.

   Our application process requires verification of household income.   Please email all supporting documents that applies to you and your household to pdintern@paulding.gov. Please make sure to place the name of the Defendant in the subject matter of the email or it will not be reviewed.  Please note that additional information may be requested after review of your application. 

   Examples of Supporting Documents:

   Last 3 Pays Stubs; Social Security/Disability Benefit, Retirement/Pension Pay Stubs; Separation Letter from Employer; Food Stamp Qualification Letter

4. Application Date:
   Application Date:
6. In Custody:

   1. Yes
   2. No
7. Date of Arrest:
   Date of Arrest:
8. Court Date:
   Court Date:
10. WARRANT / CASE NUMBER(s):
12. CHARGES:
14. Last Name
15. First Name
16. Middle Name
18. Street Address
19. Building / Apt / Suite #
21. City
22. State
23. Zip
25. Cell Phone:
26. Alt#
27. Email:
29. Date of Birth:
    Date of Birth:
30. Last 4 Digits of SSN:
31. Race:
32. Sex:
34. Name of Person That Can Always Reach You:
35. Phone Number:
39. Are You Employed?(Including Self-Employment, Part-Time or Odd Jobs)

    1. Yes
    2. No
41. Defendant Employer Name(s)
42. Length of Employment:
44. Defendant Net Take Home Pay From All Jobs (Gross pay minus State, Federal and SSN taxes)
46. Weekly
47. Bi-Weekly
48. Bi-Monthly
49. Monthly
51. Spouse's/Significant Other w/children's Employer Name(s):
52. Length of Employment:
54. Spouse's/Significant Other w/children Net (Take Home Pay) From All Jobs:
56. Weekly
57. Bi-Weekly
58. Bi-Monthly
59. Monthly
61. If unemployed, how long:
62. and how much unemployment do you receive weekly:
66. The number of your children living in your home:
67. Ages:
69. If you do not pay your own basic living expenses, state the relationship of the person who does:
71. Defendant Other Monthly Income
73. Workers Compensation:
74. Social Security:
75. Military Retirement:
77. VA Disability:
78. SSI Disability:
79. TANF/Section 8 Housing:
81. Food Stamps:
82. Other Retirement:
84. Spouse's/Significant Other With Children's Income:
86. Workers Compensation:
87. Social Security:
88. Military Retirement:
90. VA Disability:
91. SSI Disability:
92. TANF/Section 8 Housing:
94. Food Stamps:
95. Other Retirement:
97. Property or Assets: (real estate, vehicle year make & model, retirement accounts, etc.)

    List items and state estimated value

99. Expenses
101. If Child Support is not deducted from paycheck, state the amount of child support you pay:
102. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
104. If your receive child support how much do you receive:
105. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
107. Do You:

     1. Pay Rent
     2. Own Home
     3. Not Applicable
108. Monthly Rent or Mortgage Payment:
109. If You Own Your Home, Current Value:
110. If You Own Your Home, How Much is Owed:
112. If not deducted from your paycheck, list school loans, medical bills or out of the ordinary bills you are currently paying:
114. Person or Institution:
115. Payment Amount:
116. Frequency

     1. Weekly
     2. Monthly
118. Person or Institution:
119. Payment Amount:
120. Frequency

     1. Weekly
     2. Monthly
122. Currently on Probation:

     1. Yes
     2. No
123. County/City and State(s)
124. Probation Fees:
126. Bondsperson Address & Phone Number:

128. 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 DEFENDER'S OFFICE (CD) REPRESENT ME, OR THE MINOR CH ILD 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 CD. I HEREBY AUTHORIZE ANY PERSON OR AG ENCY REQUESTED BY THE CD OR ANY OF ITS EMPLOYEES TO RELEASE TO THE CD ANY INFORMATION REQUESTED TO ASS IST IN CONSIDERATION OF MY APP LICATION. INFORMATION MAY INCLUDE INFORMATION ABOUT HOUSEHOLD INCOME, EMPLOYMENT, EXPENSES, LIABILITIES, OR OTHER INFORMATON 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 CARR IES A PENALTY OF FROM ONE TO FIVE YEARS to wit: charge code 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 entry, in any matter with 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 not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.

     For each case there is an administrative fee of $50.00 payable by money order only. Please note an individual money order is needed for each case, multiple payments cannot be combined on one money order.

132. I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
134. On This Date:
     On This Date:
136. Print Name:
138. By checking the "I Agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

     1. I Agree
140. E Signature (Digital Signature):*
Leave This Blank:


142. 1. Receive an email copy of this form.
143. Email address

     This field is not part of the form submission.

144. Submit

* indicates a required field