Free mc222.pmd - Michigan

Approved, SCAO

Original - Court 1st copy - Defendant 2nd copy - Appointed attorney

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT
ORI

REQUEST FOR COURT-APPOINTED ATTORNEY AND ORDER

CASE NO.

Court address

Court telephone no.

MI-

The State of Michigan THE PEOPLE OF v

Defendant name, address, and telephone no.

CTN

SID

DOB

REQUEST The defendant requests a court-appointed attorney and submits the following information. 1. CHARGE Next hearing:
Date

Misdemeanor Felony Paternity Bond posted

Bail amount: $ 4. INCOME Employer name and address

2. RESIDENCE Rent Own 3. MARITAL STATUS Single Divorced Married Separated
Length of employment

Live with parents Room/Board Dependents:
Number

Average take-home pay $ weekly monthly
Other Income State monthly amount and source (DSS, VA, rent, pensions, spouse, unemployment, etc.).

every two weeks

5. ASSETS*

State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc.

6. OBLIGATIONS*

Itemize monthly rent, installment payments, mortgage payments, child support, etc.

7. CONTRIBUTION TOWARD ATTORNEY COSTS I understand that I may be required to contribute to the cost of an attorney. Date:
*Use reverse side for additional information/comments.

Signature:

ORDER 8.
Name Bar no.

is appointed to represent the defendant.

9. The petition is denied because:

District Court Endorsement
Date Judge MC 222 (3/09)

(felony cases only)

Date Bar no. Judge Bar no. MCR 6.005(B), MCR 6.610(D),(G)

REQUEST FOR COURT-APPOINTED ATTORNEY AND ORDER