APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM
Pursuant to §21-1-103(3), C.R.S., a processing fee of $25.00 may be collected by the court upon final disposition of this case.
Case number: _____________________Court Room: _________________________________________ District: ____________________________ Most serious charge: ________________________________________________ Next hearing date/Type: __________________________________

Applicant

All sections must be completed. Print neatly. If an item does not apply, write N/A. Applicant's Employer
Company _________________________________________________ Mailing Address ____________________________________________ Street Address (if different) _______________________________________ City, State, Zip _____________________________________________ Phone Number _____________________ Position _________________ Length of Employment _________________ Hours/Week ___________ Pay Dates: _______________________ Pay Rate: $_______________

Name ____________________________________________________ Mailing Address ____________________________________________ Street Address (if different) ____________________________________ City, State, Zip _____________________________________________ Phone number _____________________________________________ Soc. Sec. No. ____________________ Birthdate __________________ Driver's License No. ____________________ State ________________

Other Household Members (Spouse, Parent, etc.)
Name ____________________________________________________ Relation to Applicant _________________________________________ Mailing Address ____________________________________________ Street Address (if different) ___________________________________ City, State, Zip _____________________________________________ Phone number _____________________________________________ Soc. Sec. No. ________________________ Birthdate ______________ Driver's License No. ______________________ State ______________ Marital Status: Single Married Separated Divorced Gross Monthly Income (See definitions Amount on reverse for further information.) Self (wages, salary, commission) $ Spouse/Other Household Members Parents (if same household) Unemployment Benefits Social Security/Retirement Funds Maintenance/Alimony Other Income (see Page 2) Other Income (see Page 2) $ Total Household Income

Other Household Member's Employer
Company _________________________________________________ Mailing Address ____________________________________________ Street Address (if different) _______________________________________ City, State, Zip _____________________________________________ Phone Number ___________________ Position __________________ Length of Employment ________________ Hours/Week ____________ Pay Dates: _______________________ Pay Rate: $_______________

Total Number of Dependents (including yourself):___________ Monthly Expenses (See definitions on Amount reverse for further information.) Rent/Mortgage $ Groceries Utilities Clothing Maintenance/Alimony and/or Child Support Medical/Dental Other Expenses (identify source) Other Expenses (identify source)

Assets
Savings Account Balance Checking Account Balance Value of Vehicles Value of Recreation Vehicles Value of House Value of Other Property Value of Stocks, Bonds, Mutual Funds Value of Other Investments

Amount
$

Total Expenses Description
Name of Bank: Name of Bank: Year and Model: Amount Owed: $ Type: Type: Type: Year and Model:

$

Total Assets References:
1. 2.

$

Convertible to Cash = $

Name/Address/Phone ____________________________________________________________________________________ Name/Address/Phone ____________________________________________________________________________________

Guidelines: At or below or Above or In custody &/or bond allowed Out on bond ) or Automatically eligible for PD/GAL/RPC (

Refer to scoring instrument (Criminal, Misdemeanor, Traffic, Juvenile Delinquency cases ) Signature of investigator/clerk/PD:________________________________________ Date: ___________________________ I swear under penalty of perjury that the above-contained information is true and complete. I also understand that if the court grants this request, I may later be ordered to reimburse the State of Colorado for attorney fees spent on my behalf. Client signature ____________________________________________________ Signature of judicial officer: ____________________________________________ Request:
JDF 208

Date: __________________________ Date: ___________________________
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granted or

denied

R7/06 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM

APPLICTION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM General Information
It is important that you accurately complete all sections of this form as appropriate based on your personal circumstances. If a section does not apply, please write N/A .

A. Gross Monthly Income. Includes income from all members of the household who contribute monetarily to
the common support of the household. Income categories to include: Wages, including tips, salaries, commissions, payments received as an independent contractor for labor or services, bonuses, dividends, severance pay, pensions, retirement benefits, royalties, interest/investment earnings, trust income, annuities, capital gains, unemployment benefits, Social Security Disability (SSD), Social Security Supplemental Income (SSI), Workman's Compensation Benefits, and alimony. Note: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the applicant's income in a fashion which would allow the applicant proprietary rights to the roommate's income. Income categories do not include: TANF payments, food stamps, subsidized housing assistance, veteran's benefits earned from a disability, child support payments, or other public assistance programs.

B. Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit, equity, and
personal property or investments which could readily be converted into cash without jeopardizing the applicant's ability to maintain home and employment.

C. Expenses. Nonessential items such as cable television, club memberships, entertainment, dining out,
alcohol, cigarettes, etc., shall not be included. Allowable expense categories are listed on JDF 208.

JDF 208

R7/06 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM

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