NOTICE OF APPLICATION FEE AND ATTORNEY FEE: Georgia law requires every person who applies for legal defense
services under Chapter 12 of Title 17 to pay the Public Defender Office (the entity providing the services) a single fee of $50
for the application for, receipt of, or application for and receipt of such services (O.C.G.A. Section 15-21A 6(b). However, this
application fee may not be imposed if the payment of the fee is waived by the court in which you are appearing. The court
shall waive this fee if it finds that you are unable to pay the fee or that hardship will result if the fee is charged. (O.C.G.A.
Section 15-21A 6(b). Attorney fees for court- appointed representation may also be imposed by the court at sentencing.
VERIFICATION AND RELEASE: BY SUBMITTING THIS APPLICATION ONLINE, 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 PUBLIC DEFENDER'S OFFICE (CPD) REPRESENT ME, OR THE MINOR CHILD
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 CPD OR TO THE
COURT. I HEREBY AUTHORIZE ANY PERSON OR AGENCY REQUESTED BY THE CPD OR ANY OF ITS
EMPLOYEES TO RELEASE TO THE CPD ANY INFORMATION REQUESTED TO ASSIST IN CONSIDERATION OF
MY APPLICATION. INFORMATION MAY INCLUDE INFORMATION ABOUT HOUSEHOLD INCOME,
EMPLOYMENT, EXPENSES, LIABILITIES, OR OTHER INFORMATION 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
CARRIES A PENALTY OF FROM ONE TO FIVE YEARS to wit: § 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 representation; or makes or uses any false writing or document, knowing
the same to contain any false, fictitious, or fraudulent statement or entry, in any matter within 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.
I HEREBY SWEAR OR AFFIRM THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE.
BY TYPING AND SUBMITTING MY FIRST AND LAST NAME BELOW, I AM SIGNING THIS APPLICATION ELECTRONICALLY, AND I AGREE THAT
MY ELECTRONIC SIGNATURE IS THE EQUIVALENT OF MY MANUAL SIGNATURE ON THIS APPLICATION.