JURISDICTION: *

Which court is your case in?

St. Tammany Parish District Court (Covington)

Washington Parish District Court (Franklinton)

City Court of East St. Tammany (Slidell)

Bogalusa City Court

APPLYING FOR A MINOR CHILD: *

Are you filling out this application for someone under the age of 17?

Yes

No

CLIENT'S NAME: *

If you are filling this application out for your child, use your child's name, date of birth and social security number.

First Name

Last Name

DATE OF BIRTH: *

MM

DD

YYYY

ADDRESS: *

Enter mailing and physical address here: (Must include apartment number)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Apartment/Unit/Lot Number *

Do you have an apartment, lot, unit, suite or trailer number?

Yes

No

PHONE NUMBER: *

(###)

###

####

TYPE OF CASE:

What kind of case do you need legal assistance?

Adult Felony

Adult Misdemeanor

Child In Need of Care (CINC) involving DCFS

Juvenile Delinquency (person accused under 17 when alleged incident occurred)occur when under 17 yrs old.)

Child Support

Revocation

FINS (Family In Need of Services): i.e. Truancy, Ungovernable, Runaway

CHARGES: *

Do you know the charges for which you were arrested?

Yes

No

MARITAL STATUS: *

As of today, are you:

Single

Divorced

Widowed

Separated

Married

EMPLOYMENT *

Check all that apply:

Employed Full Time

Employed Part Time

Unemployed

Disability Benefits

Self Employed

SSI/Pension

SPOUSE'S EMPLOYMENT? *

If you are married, is your spouse employed?

Yes

No

Not Applicable

ASSETS:

Do you OWN any of the following assets?

House/Real Estate

Vehicle (car, boat, motorcycle, camper, etc.)

Land

Stocks/Bonds/Notes

Other

DEBTS:

Do you have any of the following debts?

Mortgage/Rent

Vehicle/Automobile

Child Support Payments

Other Debts

PUBLIC ASSISTANCE: *

Do you receive any form of public assistance? (SNAP Benefits, Disability, WIC, Housing)

Yes

No

CERTIFICATION: *

I certify under penalty of perjury that the above application is true and correct to the best of my knowledge.

AFFIRMATION: *

By submitting my application, I affirm that I desire counsel but am financially unable to procure those services and that the above information regarding my financial means and obligations is true and correct to the best of my knowledge.

DUTY TO NOTIFY: *

I hereby agree to report any changes to my name, address, phone number or financial status to the 22nd JDC Public Defender's Office.

UNDERSTANDING: *

By submitting this application, I understand that failure to pay the application fee may result in my tax refund being deducted by the amount owed to the Public Defender's Office PLUS any processing fees.

TODAY'S DATE *

MM

DD

YYYY