A. PUBLIC DEFENDER INFORMATION

I have been evaluated by the office of the State Public Defender:
NoYes
If yes, I have been found:
N/AEligibleIneligiblePartially Eligible

B. PERSONAL INFORMATION

C. EMPLOYMENT INFORMATION (Do NOT enter $, only dollar value eg: 350.)

Current Employer

Address and Telephone of Employer

Supervisor

If married and not separated (Do NOT enter $, only dollar value eg: 350.):

Spouse ́s Employer

Address and Telephone of Employer

Supervisor

D. ASSETS (Include assets of spouse if married and not separated) (Do NOT enter $, only dollar value eg: 350.)

E. NON-LIQUID ASSETS (Equity = value – money owed) (Include assets of spouse if married andnot separated) (Do NOT enter $, only dollar value eg: 350.)

F. LIABILITIES (Money owed, including that of your spouse if married and not separated) (Do NOT enter $, only dollar value eg: 350.)

G. AVERAGE MONTHLY BUDGET (Do NOT enter $, only dollar value eg: 350.)

H. FAILED ATTEMPTS TO SECURE LEGAL COUNSEL

Defendant swears that the above statements are true and correct to the best of his/her knowledge and recollection,that she/he has not sold or disposed of any assets for less than their fair market value prior to the commencement of the above-captioned proceeding in order to obtain appointed counsel and that she/he understands that furnishing false information under oath may subject him/her to a criminal prosecution, with a possible punishment of up to 10 years in the Arkansas Department of Corrections and a fine of up to $ 10,000. Further, defendant states that any change in his/her financial condition will be reported to both this Court and appointed counsel immediately.
In exchange for legal representation provided by the State, the defendant agrees to pay the amount ordered by the Court, both upon the initial Appointment of an Attorney (user fee) and for any amount ordered by the Court after the case has concluded (attorney fee). Your state income tax refund, legal settlements or favorable verdicts, lottery winnings, or any moneys or property forfeited by the State shall be intercepted to satisfy this debt under Ark. Code Ann. § 16-87-217.

Defendant's Full Name

CONTACT INFORMATION

PERSONAL INFORMATION

PREVIOUS CONVICTIONS

MEDICAL INFORMATION

CLIENT-FILE RETENTION AND DESTRUCTION

Pursuant to Arkansas Rules of Professional Conduct, Rule 1.19, the Benton County Public Defender Office will retain your client file for five (5) years after the Judgment and Commitment is filed. Thereafter, the file will be destroyed You may obtain a copy of your client file upon your written request, submitted to this office, prior to the 5-year destruction date. The cost of copying the file, after the Judgement and Commitment if filed, shall be the responsibility of the Client.