Cortland ACP Application Fillable 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 AdminstratorApplicant 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address: (if different) Alt. Active Phone:***************************************************************************************************************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 monthSocial Security Disability Income (SSDI); other disability income: $(Required) per monthSpousal support, Maintenance/Alimony (do not include Child Support): $(Required)per(Required) Unemployment Insurance Benefits:$(Required) per weekVeteran’s Benefits, Pension and/or Retirement: $(Required) per weekWorker’s Comp: $(Required) per weekOther 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: $(Required) per monthPublic Assistance, SSI/SSP (need based Social Security):$(Required) per monthChild 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?YESNOMake & Model:(Required) Value: $(Required)Amount Owed: $(Required)Make & Model:(Required) Amount Owed: $(Required)Amount Owed: $(Required)Do you own a house or real estate?(Required)YESNOWhat 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)YESNORetirement accounts (401k, IRA’s), pensions: Value: $Other assets:stocks, bonds. etcValue: $ Add RemoveEXPENSES/LIABILITIES: : Mortgage/Rent:$ per monthUtilities:$ per monthChild Care:$ per monthHealth insurance premiums or medical bills paid:$ per monthChild support/alimony actually paid:$(Required) per monthCredit Card Debt: $ per monthStudent loans: $ per monthOther expensesexpensesvalue $per Add RemoveCandidate’s Signature(Required) Date(Required) MM slash DD slash YYYY Office Use OnlyOffice Use OnlyPresumptive Circumstances: : Is the applicants’ net income below or at 250% of the FPG?(Required)YESNOIs the applicant incarcerated, detained, or confined to a mental health facility?(Required)YESNOIs the applicant currently eligible to receive need-based public assistance?(Required)YESNOWithin the last six-months has the applicant been found eligible for ACP/Public Defender/Legal Aide services on any other matter?(Required)YESNOInstructions for Court/Screener: Will the applicant be required to complete Part II?(Required)YESNOOffice Use OnlyOffice Use OnlyOffice Use OnlyOffice Use OnlyFOR COURT SCREENER ONLY: Has Bail been set:(Required)YESNOIf “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)YESNOELIGIBILITYIs the applicant eligible for assigned counsel?(Required)YESNOIf answering no, state why:Office Use OnlyOffice Use Only