Application for Services
Application for Services
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. The application must be received for review prior to the date of your scheduled court appearance. FAILURE TO TIMELY SUBMIT A FULLY COMPLETED APPLICATION MAY RESULT IN AN INITIAL DENIAL OF YOUR REQUEST FOR REPRESENTATION AND YOUR CASE BEING CONTINUED TO THE NEXT AVAILABLE COURT DATE TO ALLOW FOR PROPER REVIEW OF SAME.
An application will be included in the initial paperwork you receive from the Magisterial District Judge. Applications can be sent by mail or dropped off at the MIFFLIN COUNTY PUBLIC DEFENDER’S OFFICE located at 20 North Wayne Street, Lewistown, Pennsylvania. If your court appearance is scheduled within the next 10 days, you should immediately hand-deliver the application to the Public Defender’s office in a sealed envelope in order to prevent the disclosure of confidential information. If you drop off your Application during non-office hours, you should place your sealed envelope under the office door. The courthouse is open Monday through Friday 8 AM to 4 PM. Once your application has been processed, you will be notified as promptly as possible if your application is denied. In order to receive a response to your application, it is imperative that you provide a good, working phone number. It is your responsibility to notify the public defender office if your phone number changes at any time, and every time.
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 Assistance card or;
4. A copy of your most recent Federal Income Tax Return
5. If you can be or are claimed as a 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 OR DENIAL OF YOUR APPLICATION. PLEASE MAINTAIN THIS PAGE FOR YOUR RECORDS. IF YOU ARE IN JAIL WHEN THIS APPLICATION IS COMPLETED AND ARE SUBSEQUENTLY RELEASED, PLEASE CONTACT THE PUBLIC DEFENDER’S OFFICE IMMEDIATELY AT 717-914-6590.
APPLICATION FOR THE ASSIGNMENT OF PUBLIC DEFENDER
MAGISTRIAL DISTRICT JUDGE _________________________
DISTRICT JUDGE DOCKET NO. _____________________
COMMON PLEAS DOCKET NO. ______________________
1. Name:__________________________________________ Date of Birth: ______/______/______
2. Address: ____________________________________________________________________________
3. Home Phone No: ( ) _________________ Cell Phone No: ( ) ___________________
4. Marital Status: Single ( ) Married ( ) Divorced ( ) Separated ( )
5. Are you in jail? YES or NO Where: _________________________ Bail: __________________
6. Name, address & phone number of Current Employer:_______________________________________
Length Of Time Employed: ______________________ Gross Monthly Income:$ _________
If not currently employed, last date of employment? _________Last Employer __________________
Monthly income from Last Employer: $ ____________________________
7. Does your wife/husband work? YES or NO If so, where? __________________________________
Gross Monthly Income: $_______________
8. How many people in your house (include yourself): _________________
Names & Ages: ______________________________________________________________________
9. Do you pay support for anyone outside of your household? YES or NO Monthly amount $________
If yes, Name, age, relationship: ________________________________________________________
10. Do you have any money in a bank, savings and loan, or credit union? YES or NO
List location, type of account (savings, savings clubs, checking, certificates, etc) MUST INCLUDE current balance(s):__________________
11. Do you receive any of the following? Public Assistance ( ) Disability ( ) Social Security ( )
Unemployment ( ) Pension ( ) Other ( ) If other, please explain: _________________________
Amount received per month: $ ____________
12. Do you rent? YES or NO Rent per month $______ Landlord ______________________________
Do you live in someone else’s home? YES or NO If yes, name:_______________ Board: $________
13. Do you own your own home or any real estate? YES or NO Monthly Mortgage $________________
Original Cost $___________________________ Current Balance $___________________________
14. Other owned property and assets: ___________________________________________ Value? _______
Year and make of vehicle owned: _________________________________ Monthly Payment $_______
15. Have you ever used the services of an attorney before? ____ If yes, who? ________________________
I, the undersigned, verify that I have completed the foregoing application for appointment of Public Defender and that:
I understand that false statements made in the foregoing application are made subject to penalties of
18 Pa C.S. 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 $5,000.00, or both.
Signature of Applicant