Form Center

2. Application For Court Appointed Attorney

   Paulding County State Court Public Defender

   280 Constitution Blvd. Dallas, Ga. 30132

   Office: 678.981.4380 / Fax: 678.981.4379

   Email: PCStateCourtDefender@paulding.gov

4. Application Date:
   Application Date:
6. Booking #
7. In Custody:

   1. Yes
   2. No
8. Date of Arrest:
   Date of Arrest:
9. Court Date:
   Court Date:
11. WARRANT / CASE NUMBER(s):
13. CHARGES:
15. Last Name
16. First Name
17. Middle Name
19. Street Address
20. Building / Apt / Suite #
22. City
23. State
24. Zip
26. Cell Phone:
27. Home / Work Phone:
28. Email:
30. Date of Birth:
    Date of Birth:
31. Last 4 Digits of SSN
32. Race
33. Sex
35. Education Level:
37. Name of Person That Can Always Reach You:
38. Phone Number:
42. Are You Employed?(Including Self-Employment, Part-Time or Odd Jobs)

    1. Yes
    2. No
44. Defendant Employer Name(s)
45. Length of Employment:
47. Defendant Net Take Home Pay From All Jobs (Gross pay minus State, Federal and SSN taxes)
49. Weekly
50. Bi-Weekly
51. Bi-Monthly
52. Monthly
54. Marital Status

    1. Single
    2. Married

    1. Divorced
    2. Separated

    1. Widowed
    2. Living With Parent of Your Children
56. If Married; Spouses Name
57. Phone Number:
58. Employed:

    1. Yes
    2. No
60. Spouse Employer Name(s)
61. Length of Employment:
63. Spouse Net Take Home Pay From All Jobs (Gross pay minus State, Federal and SSN taxes)
65. Weekly
66. Bi-Weekly
67. Bi-Monthly
68. Monthly
70. If unemployed, how long:
71. If you are receiving unemployment, how much do you receive weekly:
75. The number of your children living in your home:
76. Ages:
78. List any other dependents in the home; Names, Relationship, and Amount contributed to their support:
80. If you do not pay your own basic living expenses, state the relationship of the person who does:
82. Account Information: Checking, Savings, IRA, Retirement, etc..
84. Defendant Bank Account(s)With:
85. Account Type:

    1. Checking
    2. Savings
    3. Other
86. Total Current Amount:
88. Spouse Bank Account(s)With:
89. Account Type:

    1. Checking
    2. Savings
    3. Other
90. Total Current Amount:
92. Defendant Other Monthly Income
94. Child Support:
95. Court Ordered:

    1. Yes
    2. No
96. Workers Compensation:
97. Social Security:
99. Military Retirement:
100. VA Disability:
101. SSI Disability:
103. TANF:
104. FSTA:
105. Other Retirement:
107. Other Source:
108. Amount:
109. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
111. Other Source:
112. Amount:
113. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
115. Spouse Other Monthly Income
117. Child Support:
118. Workers Compensation:
119. Social Security:
121. Military Retirement:
122. VA Disability:
123. SSI Disability:
125. TANF:
126. FSTA:
127. Other Retirement:
129. Other Source:
130. Amount:
131. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
133. Other Source:
134. Amount:
135. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
137. Property or Assets, other than typical household furnishings:

     List items and state estimated value

139. Expenses
141. If Child Support is not deducted from paycheck, state the amount of child support you're obligated to pay:
142. Frequency

     1. Weekly
     2. Biweekly
     3. Monthly
144. Do you own a motor vehicle?

     1. Yes
     2. No
145. Year
146. Make / Model
147. Amount Owed
149. Do You:

     1. Pay Rent
     2. Own Home
     3. Not Applicable
150. Monthly Rent or Mortgage Payment:
151. If You Own Home, Current Value:
152. If You Own Home, How Much is Owed:
154. If not deducted from your paycheck, list entities that you are in debt with;
156. Person or Institution:
157. Payment Amount:
158. Frequency

     1. Weekly
     2. Monthly
160. Person or Institution:
161. Payment Amount:
162. Frequency

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

     1. Yes
     2. No
165. County/City and State(s)
166. Total Amount:
168. Out on Bond:

     1. OR
     2. Property
     3. Cash
     4. Bondsman
     5. Not Applicable
169. Bond Amount Paid:
170. Who Posted Your Bond:
172. Bondsperson Address & Phone Number:

174. 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.

176. This Application is for: *Applicable Attorney Fee's May Be Assessed For Any Each Case.

     1. 1 Case
     2. 2 Cases
     3. More than 2 Cases
179. I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
181. On This Date:
     On This Date:
183. Print Name:
185. Digital Signature or Physically Sign Later:
Leave This Blank:


187. 1. Receive an email copy of this form.
188. Email address

     This field is not part of the form submission.

189. Submit

* indicates a required field