Free Application for Public Defender Services - Vermont

Form 358 Cr

Application for Public Defender Services

Notice: You may be required to provide proof of income. This may include a pay stub, a notice of decision from the Department for Children and Families, Economic Services Division, a copy of your income tax return for the prior year, or, if you have no income and did not file a return in the prior year, a sworn explanation of how you survive without income. This application is not confidential. However, any proof of income submitted to the court will remain confidential. The court may contact the Department of Taxes to verify taxable income.

State of Vermont
Name of Applicant Mailing Address

Court

Unit No.

Circuit/County Date of Birth City, State, Zip Code

Type of Case

Docket Number

F

M

MCr

A
Telephone Number (Day)

Social Security Number

Telephone Number (Evening)

Name(s) of Family Household Members

Relationship

Total Number in Household

IMPORTANT
Do you cohabit *** with anyone? Do you receive Welfare Aid*? Are you now on Probation or Parole? Relationship of Applicant to Cohabitant?

Yes No

Total Number of Dependents

Income

Assets
Location of Real Estate Owned:

Monthly Expenses

Phone Previous 30 Days Previous 12 Months Rent Cohabitant Applicant Cohabitant Applicant Fair Market Value - Outstanding Mortgage(s) = Net Worth Utilities/Fuel $ $ $ $ Gross Income from Wages $ $ $ Food Business Income less Expenses Motor Vehicles, Motorcycles, All Terrain Vehicles, Boats Clothing Year Make/Model Amount Owed Net Worth Medical Unemployment Comp. $ $ Child Support Child Support $ $ Public Assistance* Insurance: Home Cash on Hand Other Income** $ Health Checking Account(s): Bank Name & Acct. # $ $B $ $A Total $ Auto

TOTAL ANNUAL INCOME

(A+B)

$

Checking Account(s): Bank Name & Acct. # $ Savings Account(s): Bank Name & Acct. #

* Public Assistance could include: TANF/Reach Up, SSI and General Assistance ** "Other" could include Disability Insurance and Social Security *** "Cohabitant": adult family members living with applicant
Applicant's Employer: Name & Address Cohabitant's Name

$ $ $ $

Other: Other: Other:

Life Loan Payments: Motor Vehicles Home Mortgage Property Taxes Other Expenses Other: Other:

Cohabitant's Employer: Name and Address

TOTAL ASSETS $

TOTAL EXPENSES $

Notice to Applicant Request for Assignment of a Lawyer You will be ordered to pay a minimum of $25.00 toward the state's cost I request the Court to assign a lawyer to represent me in this of providing the public defender even if you are receiving public case. I further ask that all necessary costs and expenses for assistance. If you feel you do not have the ability to pay the amount legal services, as allowed by the Court, be paid by the State of ordered or if the circumstances of your case make the amount Vermont. I make the above answers UNDER PENALTY OF inappropriate, you may ask the court clerk to reduce the amount. PERJURY. Signature of Applicant Date Date The above individual personally appeared before me Notary Public and made oath to the truth of the above matters.

FINDINGS AND ORDER
1. The Applicant is Not a Financially Needy Person in that the applicant does have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to retain private counsel. 2. The Applicant is a Financially Needy Person in that the applicant does not have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to retain counsel. If counsel is assigned to represent the applicant: a. Applicant has no ability to pay. b. The applicant is ordered to pay a total of $ for the services of counsel assigned by the court. c. The applicant is ordered to pay $ as a down payment ("co-payment"'). The applicant is ordered to pay the balance of the total payment ("reimbursement") to the Clerk of the Court within 60 days of the date of this Order. Any amount due 60 days from now will be sent to the VT Tax Department for tax offset and collection.
Court Clerk/Judicial Officer Date

After reviewing the State's Attorney's information and the law enforcement officer's affidavit, the Court finds: 3. The applicant has been charged with a serious offense 4. The applicant has NOT been charged with a serious offense in that: a. The maximum penalty for the offense for which the applicant is charged does not include the possibility of a jail sentence or a fine in excess of $1,000.00. b. The Court has determined at arraignment, and stated on the record, that if the applicant is convicted, the Court will not sentence the applicant to a period of imprisonment or fine the applicant more than $1,000.00. In that the applicant is financially needy and has been charged with a serious offense, an attorney is assigned to represent the applicant. COUNSEL ASSIGNED *

COUNSEL DENIED.
* Counsel may be revoked if co-payment or proof of income is not provided. Judge Date

Notice to Applicant: You are advised that you have the right to have the clerk's determination of financial need reviewed by the presiding judge and the right to have the court clerk's determination of the amount of the payment order reconsidered by the court clerk; you also have the right, after you have requested a review or reconsideration, to appeal both determinations to a Supreme Court Justice. You may do so by contacting the Clerk of the Supreme Court by telephone (802) 828-4774 or by sending a letter to: 109 State Street, Montpelier, VT 05601-0701. Verification of income received Rev. 8/04 SML Distribution: 1 copy Court; 1 copy Applicant; 1 copy Attorney Assigned; 1 copy State's Attorney