Cortland ACP Application Fillable

APPLICATION FOR LEGAL REPRESENTATION

CORTLAND COUNTY OFFICE OF ASSIGNED COUNSEL

Cortland County Office Building – Suite B27, 60 Central Avenue
Cortland, New York 13045 Phone: (607) 428-5459 / Fax (607) 428-5458

Michael R. Cardinale, Esq., AdministratorStephanie Oliver, Secretary to Adminstrator

Applicant Name:(Required)

Social Security(Required)

Applicant Formerly Known as or Other Names:(Required)

Active Phone:(Required)

E-Mail:

D.O.B.:(Required)

Address(Required)

Street Address City State ZIP Code

Mailing Address: (if different)

Alt. Active Phone:

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Name of Court:(Required)

Please check one:(Required)

Criminal

Family

Next Court Date and Time of Appearance:(Required)

Criminal Charges:

Co-Defendants/Witnesses:

MUST HAVE FOR FAMILY COURT:

FILE#:(Required)

DOCKET #:

Previous or current public defenders or assigned counsel:

For FAMILY COURT, what type of case are you going to court for?

NOTICE

WE ENCOURAGE YOU TO INCLUDE PAPERS/CHARGES

EMPLOYMENT INFORMATION (ALL INFORMATION IS CONFIDENTIAL):

Please state the # of financial dependents in household?

Adults:(Required)

Children Under 21:(Required)

INCOME:

Place of Employment:(Required)

Net Household Income from Employment:$(Required)

per month

Social Security Disability Income (SSDI); other disability income: $(Required)

per month

Spousal support, Maintenance/Alimony (do not include Child Support): $(Required)

per(Required)

Unemployment Insurance Benefits:$(Required)

per week

Veteran’s Benefits, Pension and/or Retirement: $(Required)

per week

Worker’s Comp: $(Required)

per week

Other income:

per

Please list if you receive any of the following types of Income. Please note that this income may not be included when assessing assigned counsel eligibility:

Food Stamps: $(Required)

per month

Public Assistance, SSI/SSP (need based Social Security):$(Required)

per month

Child Support: $(Required)

per(Required)

Other Need Based Income or Subsidy:$

per

ASSETS:

Do you own more than one vehicle (list all vehicles including recreational) that is not needed for daily life activities?

Make & Model:(Required)

Value: $(Required)

Amount Owed: $(Required)

Make & Model:(Required)

Amount Owed: $(Required)

Do you own a house or real estate?(Required)

What is the fair market value?

Address:(Required)

Value: $(Required)

Amount Owed: $(Required)

Check if "Primary Residence"

Address:(Required)

Value: $(Required)

Amount Owed: $(Required)

Check if "Primary Residence"

Amount of cash on hand or in bank accounts: $(Required)

Do you own any retirement account?(Required)

Retirement accounts (401k, IRA’s), pensions: Value: $

Other assets:

stocks, bonds. etc

Value: $

EXPENSES/LIABILITIES: :

Mortgage/Rent:$

per month

Utilities:$

per month

Child Care:$

per month

Health insurance premiums or medical bills paid:$

per month

Child support/alimony actually paid:$(Required)

per month

Credit Card Debt: $

per month

Student loans: $

per month

Other expenses

expenses

value $

per

Candidate’s Signature(Required)

Date(Required)

Office Use OnlyOffice Use Only

Presumptive Circumstances: :

Is the applicants’ net income below or at 250% of the FPG?(Required)

Is the applicant incarcerated, detained, or confined to a mental health facility?(Required)

Is the applicant currently eligible to receive need-based public assistance?(Required)

Within the last six-months has the applicant been found eligible for ACP/Public Defender/Legal Aide services on any other matter?(Required)

Instructions for Court/Screener: Will the applicant be required to complete Part II?(Required)

Office Use OnlyOffice Use Only

FOR COURT SCREENER ONLY:

Has Bail been set:(Required)

If “Yes” please indicate amount:

What is the average cost of retaining private counsel in Cortland County for the applicant’s charges?

Based upon the information in this application, including the seriousness of the offense, income & expense information, and etc., will the applicant be able to afford the cost of counsel?(Required)

ELIGIBILITY

Is the applicant eligible for assigned counsel?(Required)

If answering no, state why:

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