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 firstname.lastname@example.org. 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
List items and state estimated value
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.
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