Apply for a Public Defender

APPLICATION TO ENLIST THE SERVICES OF A PUBLIC DEFENDER

I am requesting to be represented by the Public Defender because I am not financially able to hire private counsel.

How can we help you?*
- First Court Date
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Name
First Last
Phone
Date of Birth
MM slash DD slash YYYY
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Citizenship Status
- U.S Citizen
- Non-U.S. Citizen
- Military
I am unable to hire a private attorney based upon the following facts and circumstances:
Employed?
- Employed
- Unemployed
Employer Name
Occupation Please state your occupation and your employer's address and phone number.
Annual Income

Please state how much money you earn annually.
Your Expenses
Rent or Mortgage
Car Payment(s)
Medical Payment(s)
Other Loans
Insurance
Other
I declare under penalty of perjury that the foregoing is true and correct. I hereby authorize the County of Ventura and its duly authorized representatives to contact any employer, bank, savings and loan, credit union, creditor, insurance company, attorney at law, or government agency regarding my financial condition, and I further authorize such institution, individual, partnership, corporation or agency so contacted to release any and all information requested regarding my assets, liabilities, policies, litigations, financial transactions and accounts.
Signature*
Date*
MM slash DD slash YYYY

Date
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Your Expenses