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- Domestics

Application Form – Domestic

Domestics Division: Apply for a Public Defender

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Every question must be answered or your application will not be accepted.

The Public Defender’s Office may request proof of any/all answers.

Case & Client Information

Provide information regarding your case and yourself.

Hearing Type *

PFA Violation
Child Support Contempt

Hearing Date *

If your hearing date is on a Monday or Wednesday, we CANNOT represent you.

Name *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Employment & Assets

Detail your employment, income and asset information.

Are you currently employed? *

Yes
No

Employed By *

Hours per Week *

Weekly Income *

When was the last time you worked? *

For whom? *

Weekly Income *

Do you receive any form of benefits? (Unemployment, Food Stamps, etc.) *

Yes
No

Do you receive unemployment? *

Yes
No

If yes, how much? *

Unemployment amount received

Do you receive social security? *

Yes
No

If yes, how much? *

Social Security amount received

Do you receive cash assistance? *

Yes
No

If yes, how much? *

Cash Assistance amount received

Do you receive food stamps? *

Yes
No

If yes, how much? *

Food Stamps amount received

Do you receive medical assistance? *

Yes
No

If yes, how much? *

Medical Assistance amount received

Do you own or rent? *

Own
Rent

Monthly Mortgage *

Monthly Rent *

Do you own a car? *

Yes
No

Vehicle Year *

Vehicle Make *

Other Assets *

If no other known asests, type "None" or "N/A"

Monthly Bills

How much do you spend monthly on the following?

If you're not working, how do you pay bills? *

children? attorney much?

Monthly Phone Bill *

Monthly Gas/Electric Bill

Monthly Water Bill

Monthly Food Costs *

Other Monthly Bills *

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FOR PFA CONTEMPT CASES ONLY: Please complete the following specific questions.

PFA Order Issue Date *

For How Long? *

Relationship to person who filed PFA *

Do you have criminal charges for this contempt? *

Yes
No

If yes, when is your preliminary hearing date? *

Judge *

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FOR CHILD SUPPORT CONTEMPT CASES ONLY: Please complete the following specific questions.

Support Order Amount *

For how many children? *

Ages of Children *

PACSES Number *

Date of Last Payment *

Amount Paid *

Additional Comments

Provide any additional details, comments or notes regarding your case.

Affidavit

Read the affidavit carefully and sign below.

I understand the Public Defender provides free legal assistance to people who cannot afford an attorney with criminal charges against them in Delaware County. *

Yes
No

I affirm that I cannot afford to hire an attorney to represent me in my criminal case. *

Yes
No

Applicant Signature *

Please type your full name.

Today's Date *

About Us
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Join the Fight
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Apply for a Public Defender

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About Us
News
Resources
Join the Fight
Contact Us
Apply for a Public Defender

Neve | Powered by WordPress