Submit - Application for Public Defender

1. Personal Information

Are you currently incarcerated in the Northampton County Jail? *:

First name *:

Last name *:

Date of birth *:

SSN # *:

Email address:

Home phone number:

Cell phone number:

Street *:

City *:

State *:

ZIP code *:

Length of time at this address:

Residence status *:

Rent amount:

Property owner:

Marital status *:

If married, what is the name, age, and address of your spouse?

Do you have any children under the age of 18? *:

If yes, list their names and ages:

If yes, with whom do your children reside? (list guardian(s) names and addresses):

If your children do not live with you, are you paying support?

Child support amount:

Child support frequency:

If yes, list to whom you are making payments and the address:

2. Case Information

I am charged with the following offenses *:

Are you charged with a DUI? *:

If charged with a DUI, which offense?

Did you have a preliminary hearing before a Magisterial District Judge? *:

Magisterial District Judge name:

Hearing date:

Current bail amount for all charges:

Is this application for a State Parole Violation? *:

3. Employment Information

Are you employed? *:

Employer:

Employment duration:

Employment type:

Hourly rate:

If not paid hourly, what is your salary?

Pay frequency:

Paycheck method:

4. Spouse Employment

Is your spouse employed?

Spouse employer:

Spouse employment duration:

Spouse employment type:

Spouse hourly rate:

Spouse salary:

Spouse pay frequency:

Spouse paycheck method:

5. Financial & Assets

List the amounts you receive, if any, from the following:

Disability income: including Social Security, Workmen’s Compensation, etc.

Disability frequency:

Unemployment income:

Unemployment frequency:

Welfare income:

Welfare frequency:

List the amounts your spouse receives, if any, from the following:

Spouse disability income: including Social Security, Workmen’s Compensation, etc.

Spouse disability frequency:

Spouse unemployment income:

Spouse unemployment frequency:

Spouse welfare income:

Spouse welfare frequency:

Accounts with a bank or financial institution (you or your spouse)

Checking balance:

Savings balance:

Online/Mobile Bank Accounts (you or your spouse, e.g., Chime®, CashApp®, Ally®)

Online/mobile bank accounts (list types):

Online account balance:

Online money transfer services (you or your spouse, e.g., Venmo, PayPal, Zelle®, etc.)

Money transfer services (list types):

Do you or your spouse have any trusts, annuities, or estates? *:

Trusts/annuities/estate value:

Do you or your spouse own any stocks or bonds? *:

Stock/bond value:

Do you or your spouse own life insurance? *:

Life insurance value:

Make and model of automobiles:

Automobile value:

Automobile payments:

Real estate (house or land) you or your spouse own

Real estate value:

Mortgage owed:

Mortgage payment:

Additional Documents

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Declaration & Signature

I, [Full Name], residing at [Address], verify that the facts set forth in the foregoing PUBLIC DEFENDER APPLICATION are true and correct to the best of my knowledge, information and belief. I understand that false statements made therein are subject to the penalties of 18 Pa.C.S.A. §4904, relating to unsworn falsification to authorities.

I further declare that:

I have not knowingly concealed, or in any way misrepresented my financial resources.
I am indigent and unable to procure sufficient funds to obtain legal counsel to represent me.
I authorize my employer, bank, government agency, or any entity making payments to myself or my spouse to release information concerning the amount and nature of said payments to the Northampton County Public Defender’s Office.
If the Public Defender accepts my case, I will notify him or her of any changes in my financial resources including release on bail, employment, case income, or any other items listed in this application.
I am aware that I can be prosecuted for perjury if I have made any false statements, misrepresentation, or concealment.
That I can be prosecuted if I continue to accept such services after my financial condition has materially changed without notifying the Northampton County Public Defender’s Office.
That in any such case, this application may be used as evidence against me.
By signing this application, I agree to update my contact information, including my address and phone number, and I agree to update my income information within 7 days of any change. Failure to provide updated information may result in the denial of representation through the Northampton County Public Defender’s Office.

Date signed *:

Signature (type your name) *: Typing your name here will be treated as your legal signature.

Public Defender Application

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