APPLICATION FOR PUBLIC DEFENDER Juvenile Application There is a $40.00 Non Refundable Application Fee due today If payment is not made today, your application may be delayedPayments 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 Please enable JavaScript in your browser to complete this form.Juvenile's Full Name *FirstMiddleLastSuffixJuvenile Social Security No. *Juvenile Date of Birth *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDifferent Mailing AddressDifferent Mailing AddressMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTelephone *CellphoneWhat was the juvenile arrested for? *Highest Grade Completed? *Juvenile"s Current Age *Is the juvenile incarcerated or held in jail today? *YesNoIs the juvenile on probation or parole? *YesNoIs the juvenile employed? *YesNoWhere?Parent/Guardian InformationParent/Guardian Name *FirstLastEmail *EmailConfirm EmailParent Social Security No. *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you employed? *YesNoWhere?Are you married? *YesNoIs your spouse employed? *YesNoWhere?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? *YesNoName *FirstLastRelationship *Number of dependents you claimed on your Federal Income Tax Return last yearNumber of dependents, not claimed above for whom you pay supportDependent 1 NameFirstLastRelationshipAgeDependent 2 NameFirstLastRelationshipAgeDependent 3 NameFirstLastRelationshipAgeDependent 4 NameFirstLastRelationshipAgeDo you own or rent a home? *OwnRentWhat is your house note or rent per month?Do you own a vehicle? *YesNoMakeModelMileageDo you own any real estate property, other than your home or other assets such as stocks or bonds? This includes retirement accounts and pensions. *YesNoDescribe each object or property and monetary valueDo you receive Medicaid, Disability Insurance or Assistance for Needy Families? *YesNoAmount?Do you receive Public Assistance (Food Stamps) etc? *YesNoAmount?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 $40.00Price: $41.50*Includes $1.50 transaction fee.Credit CardSubmit
