Skip Ribbon Commands
Skip to main content
Public Defender Application Information

INSTRUCTIONS FOR PUBLIC DEFENDER APPLICATION

            It is the responsibility of the Office of Public Defender to provide free legal representation for any person charged with a criminal matter in Mifflin County, who, for lack of funds, is unable to afford an attorney.  You may be eligible for services.

            To apply for services, you must complete the attached application.  ALL INFORMATION MUST BE COMPLETED AND APPLICATION MUST BE DATED AND SIGNED.  Please mail or submit in person your completed application and appropriate verifications to the MIFFLIN COUNTY PUBLIC DEFENDER’S OFFICE located at the Mifflin County Courthouse, 20 N. Wayne Street, Lewistown, Pennsylvania.  Once your application has been processed, you will be notified as promptly as possible as to whether your application is approved or denied.

            Your application must be received at least ten (10) business days before your scheduled hearing.  You should have available the following financial information in the event the office has questions regarding your application.

            1.  Last four (4) pay stubs; or

            2.  Unemployment card and statement; or

            3.  Department of Public Welfare ACCESS Card; or

            4.  A copy of your most recent Federal Income Tax Return;

                                                            OR

5.  If you can be or are claimed as dependent by another person for Federal Income Tax purposes, written verification of financial information must be provided for that person.

 

FAILURE TO COMPLY WITH THESE INSTRUCTIONS WILL CAUSE DELAY IN PROCESSING YOUR APPLICATION OR DENIAL OF YOUR APPLICATION.

 

 

 

MAGISTRIAL DISTRICT JUDGE’S NAME: __________________________

DISTRICT JUDGE DOCKET NO.: __________________________

APPLICATION FOR THE ASSIGNMENT OF PUBLIC DEFENDER

1. NAME:__________________________________         DATE OF BIRTH: ____/____/____

2. ADDRESS: ____________________________________________________________________________

3. HOME PHONE NO: ( )__________ SOCIAL SECURITY NO: ______________________

4. MARITAL STATUS: Single ( ); Married ( ); Divorced ( ); Separated ( ).

5. CHARGE(S):_________________________________________________________________

DATE OF CHARGE(S): _____/_____/_____

OTHER PATICIPANTS CHARGED OR INVOLVED: _____________________________________________

HEARING DATE: ______/______/______ TIME: __________ ___.M.

HEARING TYPE: Preliminary ( ); Arraignment ( ); Juvenile ( ); Children & Youth ( ).

ARE YOU IN JAIL? YES ___/NO ___WHERE: ___________________ BAIL: ______________________

PREVIOUS CHARGES:___________________________________ ATTORNEY: ______________________

6. If not in jail, name and address of employer?____________________________________________________

Employer’s Phone No.: ( ) _________________

7. Length of time employed: __________ Gross Monthly Income:$ _______________

Total amount of income during the last 12 months: $_______________

Does your wife/husband work? YES ___/NO ___ If so, where? __________________________

Gross Monthly Income: $_______________

8. Do you have any money in a bank, savings and loan, or credit union? YES ___/NO___

List location, type of account (savings, savings clubs, checking, certificates, etc) and current

balance(s):_________________________________________________________________________

___________________________________________________________________________________

9. Do you have any money on your person or elsewhere? YES ___/NO ___ Amount: $__________

10. Do you collect any of the following? Public Assistance ( ); Disability ( ); Unemployment Compensation ( );

Social Security ( ); Other ( ). If Other, Please explain: ________________________________________

___________________________________________________________________________________

Amount per month: $______________

11. Do you rent? YES ___/NO ___ Rent per month $_________ Landlord’s name: ___________________

Do you live in someone else’s home? YES ___/NO ___

Name:__________________________________ Board: $___________

Do you own your own home or any real estate? YES ___/NO ___ Monthly Mortgage $_______________

Original Cost $_________________ Current Balance $__________________

12. Other owned property and assets: _____________________________________________________________

Year and make of vehicle owned: ________________________ Monthly Payment $_________________

13. Other debts: (state type, balance, amount of monthly payment): _______________________________

____________________________________________________________________________________________________________________________________________________________________________________

14. Do you have any credit cards? List name of card, credit limit and balance owed: ____________

__________________________________________________________________________________________

__________________________________________________________________________________________

15. How many people do you support (include yourself)? ______ Name and ages: _____________

__________________________________________________________________________________________

16. IF YOU CAN BE OR ARE CLAIMED AS A DEPENDENT BY ANOTHER PERSON FOR FEDERAL

INCOME TAX PURPOSES, YOU MUST COMPLETE THE FOLLOWING INFORMATION ABOUT

THAT PERSON:

Name(s) and address of person(s) entitled to claim you as a dependent:

__________________________________________________________________________________________

__________________________________________________________________________________________

Employer name and address:   _____________________________________________________________

Length of time employed: __________________ Gross Monthly Income: $__________________

How many people are supported? ____________

 

AFFIDAVIT

I, the undersigned, verify that I have completed the foregoing application for appointment of Public Defender and that:

 

1. I have read the foregoing application and understand its contents. The facts therein contained are true and correct to the best of my knowledge, information and belief, except as to matters therein stated to be alleged as to persons other than myself.

 

2. I authorize any person or agencies named in the foregoing application having information about my financial condition and health to release such information to any duly authorized official of the Court. In particular, I authorize and empower the Internal Revenue Service, my employers, any banks, the Department of Public Welfare and the Social Security Administration to release any information pertaining to my health or financial situation.

 

3. The foregoing application is made to inform the Court as to my financial status which could lead to the

Court appointing free counsel to defend me against the criminal charges which have been brought against me. I agree to notify the Court within 48 hours, through the Office of the Court Administrator and the Office of the Public Defender of any improvement in my financial situation from the date of this application until the final disposition of the charges.

 

4. I understand that false statements made in the foregoing application are made subject to the penalties of 18 Pa.C.S.A.§4904 relating to unsworn falsification to authorities, a conviction of which is made

punishable by not more than two years imprisonment or a fine of $5000.00, or both.

 

 

Date: _____________                                     Signature of Applicant:   ________________________________​


Copyright © 2015 Mifflin County - All Rights Reserved.
Site hosted and developed by CCAP