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2. STATE OF MICHIGAN*

   1. 60TH JUDICIAL DISTRICT
   2. 14TH JUDICIAL CIRCUIT
3. CASE NO.
4. Judge (name)
8. THE PEOPLE OF THE STATE OF MICHIGAN
9. V
11. Name*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. CTN #(if known)
21. SID (if known)
23. E-mail address
24. Text messages

    1. I wish to receive text message notifications for all scheduled hearings in this case
28. REQUEST
    The defendant requests a court-appointed attorney and submits the following information.
30. 1. CHARGE
31. SELECT ONE*

    1. Misdemeanor
    2. Felony
    3. Paternity
33. Next hearing date and time
    Next hearing date and time

    Next hearing date and time
34. Bail amount $
35. Bail posted:

    1. yes
    2. no
39. 2. RESIDENCE *

    1. Rent
    2. Own
    3. Live with parents
    4. Room/Board
40. 3. MARITAL STATUS *

    1. Single
    2. Married
    3. Divorced
    4. Separated
41. 4. Number of Dependents*

    1. None
    2. One
    3. Two
    4. Three
    5. Four
    6. More than four
45. 5. INCOME*
    Employer name and address
47. Length of employment *
48. Average take-home pay*
49. Pay period*

    1. Weekly
    2. Monthly
    3. Every two weeks
    4. Twice Monthly
53. 6. ASSETS*
    State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc.
55. 7. OBLIGATIONS*
    Itemize monthly rent, installment payments, mortgage payments, child support, etc.
57. 8. CONTRIBUTION TOWARD ATTORNEY COSTS
    I understand that I may be required to contribute to the cost of an attorney.
61. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
63. Electronic Signature*
64. Date*
    Date
68. ORDER

    1. 9. The petition is denied because:
    2. ...................Applicant deemed not indigent
    3. ...................Conviction will not result in mandatory jail time
    4. 10. The defendant is referred to the local appointing authority for indigency screening and appointment of an attorney, if appropriate.
    5. 11. The defendant is financially unable to retain an attorney and is referred to the local appointing authority for appointment of an attorney.
70. Judge signature
71. Date
73. Form MC 222, Rev. 7/20
    MCR 6.005(B), MCR 6.610(D),(G)
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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field