Notice to jail personnel and/or any law enforcement agents, and/or any prosecutors: by placing my name on and/or fully or partially filling out this form, I am hereby invoking my right to counsel as secured by the fifth, sixth and fourteenth amendments to the United States Constitution and Article 1, Section 1, Paragraphs xiv and xvi of the Constitution of the State of Georgia, and am affirmatively Stating that I do not wish to speak with any agent of the state in any investigatory capacity or answer any questions about these or other vending or potential charges or any matter related in any manner to these or other pending or potential charges.

IN THE (SUPERIOR) (STATE) COURT OF __________ COUNTY
STATE OF GEORGIA

APPLICATION FOR APPOINTMENT OF COUNSEL AND CERTIFICATE OF FINANCIAL RESOURCES

I am the defendant in the above-styled action. I am charged with the offense(s) of ________, which is/are a felony/misdemeanor. I cannot afford to hire a lawyer to assist me. I request that I be provided with a lawyer. I understand that I am providing this information in this declaration in order for a determination to be made of my eligibility for an appointed lawyer or public defender, paid by ___________ County,
to defend me on the above charges.

In jail......Out on bond......Arrest Date

1. Name _______________________
Telephone No. _____________________
Mailing address _______________________________________________
Birth date _____________
Age ________
Soc. Sec. No. ___________________
Highest grade in school completed ____________________________________

2. If employed, employer is __________________________________________
Net take home pay is (gross pay minus state, federal and social security taxes): 
___________ (weekly) ___________(monthly)

3. If unemployed, how long?________ List other sources of income such as unemployment compensation, welfare or disability income and the amounts received per week or month:
_______________________________________________

4. Are you married?______
Is spouse employed? _____
If yes, by whom _______________________________
Spouse's net income
___________ (weekly) ___________(monthly)

5. Number of children living in home: ____
Ages _________________________

6. Dependents (other than spouse or children) in home, names, relationship, amount contributed to their support
_______________________________________________
7. Do you own a motor vehicle? _____
Year and model ______________________
How much do you owe on it? ___________________

8. Do you own a home? _____
Value __________
How much do you owe on it? _______

9. Amount of house payment or rent payment each month _______________

10. List checking or savings accounts or other deposits with any bank or financial institution and the amount of deposits: _______________

11. List other assets or property, including real estate, jewelry, notes, bonds or stocks:
_______________________________________________

12. List indebtedness and amount of payments: _______________________________________________

13. List any extraordinary living expenses and amount (such as regularly occurring medical expenses):
_______________________________________________

14. Child support payable under any court order: _______________________

15. Do you understand that whether you are convicted or acquitted __________
County may seek reimbursement of attorney's fees paid for you if you become financially able to pay or reimburse the county but refuse to do so? _____________

_____ I have read (had read to me) the above questions and answers and they are correct and true.

The undersigned swears that the information given herein is true and correct and understands that a false answer to any item may result in a charge of false swearing.

The ______ day of __________________, 200__.

___________________
Defendant's Signature

Sworn to and subscribed before me
this _____ day of _________, 200__.

___________________
Notary Public

[NOTE: To prevent the inadvertent or improper release of confidences or secrets, the Order of Appointment below should be produced on a form separate and apart from the "Application for Appointment of Counsel and Certificate of Financial Resources."]

APPOINTMENT OF COUNSEL

Upon consideration of the Application for appointment of counsel the above-named defendant is found to be indigent/not indigent under criteria of the Georgia Indigent Defense Act and appropriate court rules and is/is not entitled to have appointed counsel.

Attorney _____________________, or the Public Defender's Office is appointed to represent the defendant. The appointed attorney/Public Defender shall promptly make contact with the defendant after actual notice of appointment.

________________________________
Administrator of Indigent Defense Program or Designee 

cc: Public Defender/Appointed Attorney _________________
Clerk, District Attorney, Sheriff/Law Enforcement Custodian Indigent Accused (At detention facility or home address if released)