Application: Court Appointed Attorney Child’s Information IN THE INTEREST OF (Child’s First and Last Name): * IN THE INTEREST OF (Child's First and Last Name): First First Last Last FILE NUMBER Fulton Juvenile Court’s File Number CASE NUMBER Fulton Juvenile Court’s Case Number will include a “DP”, “SP”, “DL” or “CH” Child’s Gender * Male Female Transgender Child’s Age * Child’s Date Of Birth: * Household Information Total Number of Family Members who live in my household: * Number of Adults in Household * Number of Children in Household * Income/Take-Home Pay (If You Do Not Receive Any Income, Input 0): $ I am paid (Frequency/How often are you paid?) * Weekly Bi-Weekly (every two weeks) Monthly I am not employed HOUSING:(ex. Mortgage, Rent) My Monthly Housing Expenses are (list amount) $ MONTHLY UTILITIES (ex. Electric, Gas, Water, etc): My Monthly Utilities Expenses (list amount) $ TRANSPORTATION (ex. Car Payment, Bus Pass/Fare, etc.): My Monthly Transportation Expenses (list amount) $ My OTHER Monthly Expenses (ex. Cellphone, Internet, Insurance, Groceries, Child Care, Child Support) $ My TOTAL Monthly Expenses (TOTAL Housing, Transportation, Utilities and Other Expenses) $ I hereby affirm that the above information is true and correct. * I Agree Agreement and Applicant Information I hereby affirm that the above information is true and correct. * I Agree I am indigent and without sufficient funds to pay for an attorney without undue hardship on my family. * I Agree I request that an attorney be appointed to represent me/my child in the above-styled matter. * I Agree Electronic Signature Agreement By selecting the “I Accept” button, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Application. By selecting “I Accept” using any device, means or actions agree that your signature on this document (hereafter referred to as your “E-Signature”) is as valid as if you signed the document in writing. * I Accept Applicant’s Electronic Signature: * signature keyboard Clear Print Applicant’s Full Name (Applicant’s First and Last Name) * Print Applicant's Full Name (Applicant's First and Last Name) First First Last Last Applicant’s Relationship to Child * Mother Father Legal Custodian Legal Guardian Other If “Other” to the above question, please elaborate Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number * Email Address * If you are human, leave this field blank. 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