Fillable Application For Public Defender Services - JUVENILE (Vermont Judiciary)

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Application For Public Defender Services - JUVENILE (Vermont Judiciary)

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APPLICATION FOR PUBLIC DEFENDER SERVICES - Juvenile
400-00358J Application for Public Defender – Juvenile (04/2019) Page 1 of 2
State of Vermont
Vermont Superior Court
Division
Unit
Type of Case
Docket Number
FAMILY
Name
First
Last
Mailing Address
Town/City
State
Zip
Telephone Number
Date of Birth
Social Security Number
Total Number of Family Members in Household (including
yourself)
EMPLOYMENT
Are you employed? Yes ☐ No ☐
If Yes, fill in employer’s name(s) and address(es)
Hourly rate of pay $______________
Hours worked per week_____________
Employer(s) Name(s) and Address(es):
INCOME
Yes
No
If all adults living with you receive public assistance, it is not
necessary to fill out the Expenses section below.
Otherwise, enter your monthly household expenses.
Do you receive Public Assistance? (TANF/Reach UP; SSI,
General Assistance)
☐
☐
Any family members living with you receive assistance?
☐
☐
Current Monthly Income
Rent or Mortgage Payment
$________________
You
Other Family Household
Members Living with You
Electric Service
Phone
$________________
$________________
Gross Income from Wages
$____________
$___________
Fuel (heat and/or gas)
$________________
Self-Employment/Business Income
(other than wages)
$____________
$___________
Food
$________________
Unemployment Compensation
$____________
$___________
Clothing
$________________
Child Support
$____________
$___________
Medical
$________________
Public Assistance
$____________
$___________
Child Support
$________________
Other Income (Including Disability Insurance
and Social Security)
$____________
$___________
Auto Loan Payments
$________________
Total Income
$
$
Property Taxes
$________________
Total Monthly Income
(Your income plus family household members)
$
Insurance (include Health, Auto, etc.)
$________________
Total Income in the past 12 months
$
Other Expenses
$________________
Is your income in the last 30 days significantly different from
your monthly income during the previous year?
Yes
☐
No
☐
If YES, please explain the circumstances on the next page.
Total Expenses
$
Cash Assets
Other Assets
Real Estate (Location)
Auto (Make, Model, Year)
Cash On Hand
$__________
______________________
______________________
Checking Account
$__________
Fair Market Value
$_________________
$__________________
Savings Account
$__________
Outstanding
Mortgage/Loan
$_________________
$__________________
Total Cash Assets
$__________
Net Value
$_________________
$__________________
NOTICE: You may be ordered to pay a minimum fee towards the cost of your legal services even if you are receiving public assistance. You may
ask the Court to reduce the amount you are ordered to pay.
Additional Assets:
I have additional assets: Yes ☐ No ☐
If Yes, describe them below
Vehicles
Make, Model, Year
Fair Market Value
(FMV)
Amount Owed
Net Value
$
$
$
$
$
$
APPLICATION FOR PUBLIC DEFENDER SERVICES - Juvenile
400-00358J Application for Public Defender – Juvenile (04/2019) Page 2 of 2
Real Property
Description
Fair Market Value
(FMV)
Mortgage
Net Value
$
$
$
$
$
$
Other Assets (tools, equipment,
recreational vehicles, electronics, stocks,
bonds, etc.)
Description
Fair Market Value
(FMV)
Use additional sheets as necessary.
$
$
Other Employed Family Household Members
Name of Family Member
Name of Employer
Employer’s Address
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 the juvenile in this 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:
Notary Public
Date
Applicant Signature
Date
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
Date
Findings and Order
The Court has reviewed the Petition and Affidavit and finds that:
☐ The interests of justice require representation of the Juvenile.
☐ The interests of justice require representation of the Applicant.
☐ The interests of justice do NOT require representation of the Applicant.
It is hereby ORDERED:
☐ Counsel ASSIGNED to Juvenile.
☐ Counsel ASSIGNED to Applicant in that applicant is financially needy and the interests of justice so require.
☐ Counsel DENIED to Applicant.
Signature of Judge
Date
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.
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Application For Public Defender Services - JUVENILE (Vermont Judiciary)

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Completed 15 July 2020

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