Any law enforcement authority having custody of any person shall:
IN THE SUPERIOR COURT OF ____ COUNTY
STATE OF GEORGIA
STATE OF GEORGIA INDICTMENT NO.
APPLICATION FOR APPOINTMENT OF COUNSEL AND
CERTIFICATE OF FINANCIAL RESOURCES
I am the defendant in the above styled action. I am charged with the offense(s) of ________________ which is/are a felony/misdemeanor. I can/cannot afford to hire a lawyer to assist me. I do/do not want the court to provide me with a lawyer. I understand that I am providing this information in this declaration in order for the court to determine my eligibility for a court appointed lawyer, paid by ________ County, to defend me on the above charges.
In jail ________ Out on bond ________ Arrest Date _______
Mailing address ____________________________________________
Birth date _______ Age _____ Soc. Sec. No. _________________
Highest grade in school completed ___________________________
Net take home pay is (gross pay minus state, federal
and social security taxes): ________ (weekly) ________ (monthly)
If yes, by whom _________ Spouses net income (week) _______________
How much do you owe on it? ______________________________
___________________________________________________________________________
I have read (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 charge of perjury.
The ______ day of _________, 19__.
_________________________
Defendants Signature
Sworn to and subscribed before me this ______ day of ____________, 19__.
__________________________________ Notary Public My Commission Expires _______
Having considered the above matter, it is the finding of this court that the above named defendant is/is not indigent under criteria of the Georgia Criminal Justice Act and appropriate court rules and is/is not entitled to have appointed counsel.
It is ordered that the clerk, panel administrator, or court administrator assign an attorney practicing in this county to represent the defendant in the above case.
Let the defendant and the assigned attorney be notified hereof and furnished a copy of this application and order.
This ______ day of ___________, _____.
______________________
Superior Court Judge
_________ Judicial Circuit
Ga. R. Sup. Ct. 29.3