APPLICATION FOR PUBLIC DEFENDER SERVICES - Criminal
200-00358CR Application for Public Defender – Criminal (09/2019) Page 2 of 2
Other Assets (tools, equipment,
recreational vehicles, electronics, stocks,
bonds, etc.)
Use additional sheets as necessary.
Other Employed Family Household Members
Change in Monthly Income: If your current monthly income is significantly different from last year’s income, please describe your current monthly
income and the reasons why it changed.
My income last year (past 12 months) was:
The income from other family household members last year was:
The reason for the change is: (This section must be filled out if you have a change in income)
I request the Court assign a lawyer to represent me in the case because of my low income. I further ask that all necessary costs and expenses for
legal service, as allowed by the court, be paid by the State of Vermont. I make the above answers UNDER PENALTY OF PERJURY.
Signed and sworn before me:
Determination of Financial Eligibility
☐ Applicant is not a financially needy person in that applicant has sufficient income to retain private counsel and/or has sufficient liquid or non-
liquid assets which could provide collateral to borrow funds to retain private counsel.
☐ Applicant is a financially needy person in that applicant does not have sufficient income to retain private counsel and does not have sufficient
liquid or non-liquid assets which could provide collateral to borrow funds to retain private counsel.
☐ Minimum Payment: Applicant’s household income is under 125% of poverty. Applicant is ORDERED to pay the minimum payment of $50
within 60 days unless this fee is waived by the Court.
☐ Immediate Copayment: Applicant’s annual household income is above 125% of poverty and applicant has income and assets available to
support an immediate copayment to cover a part of the cost of services.
Applicant shall pay $______________ to the Clerk of the Court.
☐ Reimbursement Order: Applicant’s annual household income is above 125% of poverty and applicant has income and assets available to
reimburse the state for the cost of services.
Applicant shall pay $______________ to the Clerk of the Court within 60 days of the date of this Order.
NOTICE: If Public Defender Assessment and reimbursement is not fully paid within 60 days, any amount still due will be sent to the Tax
Department for offset and collection agency.
Signature of Clerk or Designee
The Court has reviewed the Information and Affidavit and finds that:
☐ The Applicant has been charged with a serious offense.
☐ The Applicant has not been charged with a serious offense in that:
☐ The maximum penalty for the offense for which the Applicant is charged does not include the possibility of a jail sentence or a fine in excess
of $1,000.00.
☐ The Court has determined at arraignment and stated on the record, that if the Applicant is convicted, the Court will not sentence the
Applicant to a period of imprisonment or fine the Applicant more than $1,000.00.
☐ Court waives fee.
It is hereby ORDERED:
☐ Counsel ASSIGNED in that Applicant is financially needy and is charged with a serious offense.
☐ Counsel DENIED.
Notice of Right to Appeal: You have the right to appeal this Order to the Judge of this Court. Your appeal must be in writing with the Clerk of this
Court within 7 days of the date of this Order. You may appeal a Judge’s decision to the Supreme Court.
