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2. Case Number*
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Telephone Number*
14. Email Address
18. REQUEST: The defendant requests a court-appointed attorney and submits the following information:
20. Residence*

    1. Rent
    2. Own
    3. Live With Parents
    4. Room/Board
21. Marital Status*

    1. Single
    2. Married
    3. Divorced
    4. Separated
22. Dependants (number of)*
24. Source of Income: (please include employer name and address)*
26. Length of Employment*
27. Average take-home pay (dollar amt)*
28. Amount Per:*

    1. Weekly
    2. Every two weeks
    3. Monthly
30. Other Income: Monthly amount from DHHS, VA, Rent, Pensions, Unemployment, etc. (total of from all sources)*
32. Assets: Value of car, home, bank deposits, inmate accounts, bonds, stocks, etc. (total from all sources)*
34. Obligations: (itemize rent, installment payments, mortgage payments, child support, etc.)*
36. CONTRIBUTION TOWARD ATTORNEY COSTS
    I understand that I may be required to contribute to the cost of an attorney.
38. 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. I have reviewed this document and the statements it contains are true to the best of my knowledge, information, and belief.

    1. I agree.
40. Electronic Signature*
41. Date*
    Date
45. ORDER
    __________________________________________ is appointed to represent the defendant. (include Name and Bar number)
47. The petition is denied because: Applicant deemed not indigent ______ Convictions will not result in mandatory jail time ______
49. Date
    ________________________________________
50. Judge / Bar no.
    _________________________________________________________
52. Mailed ______ Handed to Defendant ______ Date ______________________ Initials ______
54. MCR 6.005(B), MCR 6.610(D),(G)
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field