JDF 208 R10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM Page 1 of 2
APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM
Pursuant to §21-1-103(3), C.R.S., a processing fee of $25.00 may be collected by the court upon final disposition of this case.
Case number: _____________________Court Room: _________________________________________ District: ____________________________
Most serious charge: ________________________________________________ Next hearing date/Type: __________________________________
All sections must be completed. Print neatly. If an item does not apply, write N/A.
Applicant
Applicant’s Employer
Name ____________________________________________________
Mailing Address ____________________________________________
Street Address (if different) ____________________________________
City, State, Zip _____________________________________________
Phone number _____________________________________________
Soc. Sec. No. ____________________ Birthdate __________________
Driver’s License No. ____________________ State ________________
Company _________________________________________________
Mailing Address ____________________________________________
Street Address (if different) _______________________________________
City, State, Zip _____________________________________________
Phone Number _____________________ Position _________________
Length of Employment _________________ Hours/Week ___________
Pay Dates: ______________________ Pay Rate: $_______________
Other Household Members (Spouse, Partner, Parent, etc.)
Other Household Member’s Employer
Name ____________________________________________________
Relation to Applicant _________________________________________
Mailing Address ____________________________________________
Street Address (if different) ___________________________________
City, State, Zip _____________________________________________
Phone number _____________________________________________
Soc. Sec. No. ________________________ Birthdate ______________
Driver’s License No. ______________________ State ______________
Company _________________________________________________
Mailing Address ____________________________________________
Street Address (if different) _______________________________________
City, State, Zip _____________________________________________
Phone Number ___________________ Position __________________
Length of Employment ________________ Hours/Week ____________
Pay Dates: _______________________ Pay Rate: $_______________
Marital Status: Single Married Partner in a Civil Union Separated Divorced/Civil Union Dissolved Total Number of Dependents (including yourself):
Gross Monthly Income (See definitions on
reverse for further information.)
Amount
Monthly Expenses (See definitions on reverse for further
information.)
Self (wages, salary, commission)
$
Rent/Mortgage
$
Spouse/Partner/Other Household Members
Groceries
Parents (if same household)
Utilities
Unemployment Benefits
Clothing
Social Security/Retirement Funds
Maintenance (Spousal/Partner Support) and/or Child Support
Maintenance (Spousal/Partner Support)
Medical/Dental
Other Income (see Page 2)
Other Expenses (identify source)
Other Income (see Page 2)
Other Expenses (identify source)
Total Household Income
$
Total Expenses
Assets
Amount
Description
Savings Account Balance
$
Name of Bank:
Checking Account Balance
Name of Bank:
Value of Vehicles
Year and Model:
Value of Recreation Vehicles
Amount Owed: $
Value of House
Type:
Value of Other Property
Type:
Value of Stocks, Bonds, Mutual Funds
Type:
Value of Other Investments
Year and Model:
Total Assets
$
Convertible to Cash = $
References:
1. Name/Address/Phone ____________________________________________________________________________________
2. Name/Address/Phone ____________________________________________________________________________________
Guidelines:
At or below or Above or
Automatically eligible for PD/GAL/RPC (In custody &/or bond allowed Out on bond) or
Refer to scoring instrument (Criminal, Misdemeanor, Traffic, Juvenile Delinquency cases)
Signature of investigator/clerk/PD: ________________________________________ Date: ___________________________
I swear under penalty of perjury that the above-contained information is true and complete. I also understand that if the court grants this
request, I may later be ordered to reimburse the State of Colorado for attorney fees spent on my behalf.
Client signature ____________________________________________________ Date: __________________________
Signature of judicial officer: ____________________________________________ Date: ___________________________
Request: granted or denied
JDF 208 R10/2015 APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED COUNSEL, OR GUARDIAN AD LITEM
Page 2 of 2
APPLICATION FOR PUBLIC DEFENDER, COURT-APPOINTED
COUNSEL, OR GUARDIAN AD LITEM
General Information
It is important that you accurately complete all sections of this form as appropriate based
on your personal circumstances. If a section does not apply, please write N/A.
A. Gross Monthly Income. Includes income from all members of the household who
contribute monetarily to the common support of the household.
Income categories to include:
Wages, including tips, salaries, commissions, payments received as an independent
contractor for labor or services, bonuses, dividends, severance pay, pensions,
retirement benefits, royalties, interest/investment earnings, trust income, annuities,
capital gains, unemployment benefits, Social Security Disability (SSD), Social Security
Supplemental Income (SSI), Workman’s Compensation Benefits, and alimony.
Note: Income from roommates should not be considered if such income is not commingled in
accounts or otherwise combined with the applicant’s income in a fashion which would allow the
applicant proprietary rights to the roommate’s income.
Income categories do not include:
TANF payments, food stamps, subsidized housing assistance, veteran’s benefits earned
from a disability, child support payments, or other public assistance programs.
B. Liquid Assets. Includes cash on hand or in accounts, stocks bonds, certificates of deposit,
equity, and personal property or investments which could readily be converted into cash
without jeopardizing the applicant’s ability to maintain home and employment.
C. Expenses. Nonessential items such as cable television, club memberships, entertainment,
dining out, alcohol, cigarettes, etc., shall not be included. Allowable expense categories
are listed on JDF 208.
If you are applying to have your filing fee waived, you may be asked to
supply:
Copies of the previous three months bank statements, including checking and savings.
DO NOT provide originals.
Copies of the previous three months pay stubs and/or proof of income must be included.
DO NOT provide originals.
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