IN THE STATE COURT OF FULTON COUNTY

STATE OF GEORGIA
STATE OF GEORGIA
vs.

Accusation No.:_____________________________________

____________________________________________________
Defendant
APPLICATION FOR INDIGENT STATUS
I am the Defendant in the above-styled action. I am charged with the offense (s) of: _________________________________
________________________________________________________________, which is/are a misdemeanor(s). I cannot afford to
pay for counseling. I request that I receive sliding scale rates for counseling.
Name: _____________________________________________________________ Home phone: ____________________________
Address (incl. Apt #): ____________________________________________________ City: _________________________________
State: ___________ Zip: ___________ County: ________________ SS#: _________________________ D.O.B. ________________
Highest grade completed: ______ Minor Children in home: ______Number of other dependants: ________ Marital Status: _________
Are you employed? YES - NO Employer: _______________________________________________________________________
Length of employment: ________________________________ Length of unemployment ___________________________________
PLEASE INDICATE (CIRCLE) WHETHER THESE AMOUNTS ARE WEEKLY, BI-WEEKLY, EVERY TWO WEEKS, OR MONTHLY.

Take Home Pay: $___________________ Other income: $__________________

Are you court ordered to pay child support? YES - NO

Amount: $_______________ Do you receive child support? YES - NO

Amount: $______________________________________ Other extra ordinary expenses: $_________________________________

Car: YES - NO Year:______ Make: ______________ Model: ____________ Monthly payment: $_________ Balance: $_________
House/Apartment: Own Rent

Monthly payment: $________________ Balance: $________________ Other: _______________

Living with a friend or relative? YES NO Do you pay this person rent? YES NO How Much? $__________________________
I have read (or had read to me) the above questions and answers and they are correct and true. The undersigned swears that
the information given herein is true and correct and understands that a false answer to any item may result in a charge of perjury.
This ___________ day of _________________________, 2011.
___________________________________________
Defendants Signature
Upon consideration of the Application for indigence status the defendant is found to be indigent/not indigent under criteria of
the Georgia Indigent Defense Act and appropriate court rules and is/is not entitled to have appointed counsel.
This _____________ day of _____________________________, 2011.
________________________________________
Judge, State Court of Fulton County