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828 S. Irma Blvd, Suite 102, Gonzales, LA 70737
225-647-9673
23rdjdcpdo@gmail.com

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23rd Judicial District

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Adult Application For Public Defender

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Adult Application For Public Defender

APPLICATION FOR PUBLIC DEFENDER

Adult Application

There is a $40.00 Non Refundable Application Fee due today If payment is not made today, your application may be delayed

Payments can be paid in person at 828 S. Irma Blvd, #102, Gonzales, LA 70737

False answers are punishable by a fine or jail All Questions Must Be Answered

Full Name *

First

Middle

Last

Suffix

Email *

Email

Confirm Email

Social Security No. *

Date of Birth *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Different Mailing Address

Different Mailing Address

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Telephone *

Cellphone

What charge were you arrested for? *

Highest Grade Completed? *

Current Age *

Are you incarcerated or held in jail today? *

Yes
No

Are you on probation or parole? *

Yes
No

Are you employed? *

Yes
No

Where?

Are you married? *

Yes
No

Is your spouse employed? *

Yes
No

Where?

Total Monthly income from you and your spouse (gross before deductions) from all sources including your jobs, disability, family assistance, child support and public assistance (welfare) *

Does anyone else support you? *

Yes
No

Name

First

Last

Relationship

Number of dependents you claimed on your Federal Income Tax Return last year

Number of dependents, not claimed above for whom you pay support

Dependent 1 Name

First

Last

Relationship

Age

Dependent 2 Name

First

Last

Relationship

Age

Dependent 3 Name

First

Last

Relationship

Age

Dependent 4 Name

First

Last

Relationship

Age

Do you own or rent a home? *

Own
Rent

What is your house note or rent per month?

Do you own a vehicle? *

Yes
No

Make

Model

Mileage

Do you own any real estate property, other than your home or other assets such as stocks or bonds? This includes retirement accounts and pensions. *

Yes
No

Describe each object or property and monetary value

Do you receive Medicaid, Disability Insurance or Assistance for Needy Families? *

Yes
No

Amount?

Do you receive Public Assistance (Food Stamps) etc? *

Yes
No

Amount?

By signing this document I certify to the Court, under penalty of contempt of court that all of my answers are true and correct to the best of my knowledge. *

Clear Signature

Application Fee $40

Price: $41.50

*Includes $1.50 transaction fee.

Credit Card

The Office of the Public Defender for the 23rd Judicial District represents indigent individuals in the Parishes of Ascension, Assumption, and St. James.

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