Chatham County Office of the Circuit Public Defender

Use this online form to apply for services. Fill out all **(*) required** and as many fields as you can.

You may also complete and print the Application for Services and either bring it with you to our office or fax it to us at (912) 447-4909.

Application for Services

Map & Directions to our Office

Personal Info

E-mail Address
A copy of the completed application form will be sent to the address provided.

Name

Last *

First *

Middle

Other Name(s)

Case Number(s)

Charges

Co-Defendants

Address *

Street

City

State

Zipcode

Phone Number *
Only one phone number type is required.

Home

Cell

Work

Date of Birth *

Race *

Sex *

The person who can always reach you

Name

Phone #

Address

Marital Status

Spouse's Name

Is your spouse employed?

Yes No

Ages of your children who live in the house with you

List any other dependents

Employment

Are you employed? *
(including self-employment, part-time work, or "odd jobs")

Yes No

Income

Net Income *
(total income, minus deductions required by law and child support payments deducted from paycheck)

per

If child support not deducted from check, state amount of child support obligation

per

If incarcerated, do you have income while in jail?

Yes No

Do you receive child support?

Yes No

Do you receive unemployment or workers compensation?

Yes No

Do you receive: Military, VA, Social Security, SSI, TANF, Food Stamps, or Retirement benefits?

Yes No

If you do not pay your own basic living expenses, state the relationship of the person who does

Are you disabled?

Yes No

Does anyone else claim you as a dependent for tax purposes?

Yes No

Other payments you receive from any source

Things You Own

Money *
(cash, checking accounts, savings accounts, retirement accounts, inmate accounts)

Motor Vehicles

Year/Model/Make

Est. Value ($)

Is any real estate titled in your name?

Yes No

Other assets or property
(other than usual and customary household furnishings)

List and state Est. Value ($)

Miscellaneous

Probation: Court ordered monthly payment

Unusual Expenses
(other than basic living expenses)

Type and Amount

Assistance
(If applicable, the understated person provided assistance to the defendant/child with the completion of this form due the defendant's inability to read and write.)

Assistant's Name

Assistant's Phone #

Assistant's Address

Number of cases this application is for
(I understand that I will be assessed an application fee and any applicable attorney fees for each case.)

case(s)

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.

Signature (First and Last Name)

Online Application

Use this online form to apply for services. Fill out all (*) required and as many fields as you can.

Personal Info

Employment

Income

Things You Own

Miscellaneous

Assistance (If applicable, the understated person provided assistance to the defendant/child with the completion of this form due the defendant's inability to read and write.)

Use this online form to apply for services. Fill out all **(*) required** and as many fields as you can.

Assistance
(If applicable, the understated person provided assistance to the defendant/child with the completion of this form due the defendant's inability to read and write.)