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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

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Full Name *

First

Middle

Last

Suffix

Email *

Email

Confirm Email

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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

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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

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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

Dependent 1 Name

First

Last

Relationship

Age

Dependent 2

Dependent 2 Name

First

Last

Relationship

Age

Dependent 3

Dependent 3 Name

First

Last

Relationship

Age

Dependent 4

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

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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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