Ga. Unif. Super. Ct. R. 29.3

Any law enforcement authority having custody of any person shall:

(A) Allow a person claiming to be indigent and without counsel to immediately complete an

application for an attorney and certificate of financial resources and forward such to the court or

its designee, for a determination of indigency or not;

(B) Clearly advise detained persons of their right to have counsel and that if they cannot afford a

lawyer one will be provided to assist them;

(C) Accomplish the above procedures as soon as possible after detention; and,

(D) Complete an application for an attorney and certificate of financial resources in substantially

the following form:

IN THE SUPERIOR COURT OF ____ COUNTY

STATE OF GEORGIA

STATE OF GEORGIA INDICTMENT NO.

v. CHARGE(S):

___________________

APPLICATION FOR APPOINTMENT OF COUNSEL AND

CERTIFICATE OF FINANCIAL RESOURCES

I am the defendant in the above-styled action. I am charged with the offense(s) of

________________ which is/are a felony/misdemeanor. I can/cannot afford to hire a lawyer to

assist me. I do/do not want the court to provide me with a lawyer. I understand that I am

providing this information in this declaration in order for the court to determine my eligibility for

a court-appointed lawyer, paid by ________ County, to defend me on the above charges.

In jail ________ Out on bond ________ Arrest Date _______

1. Name ______________ Telephone No. _______________________

Mailing address ____________________________________________

Birth date _______ Age _____ Soc. Sec. No. _________________

Highest grade in school completed ___________________________

2. If employed, employer is _________________________________

Net take home pay is (gross pay minus state, federal and social security taxes):

________ (weekly) ________ (monthly)

3. If unemployed, how long? __________ List other sources of income such as unemployment

compensation, welfare or disability income and the amounts received per week or

month:________________.

4. Are you married ______ Is spouse employed? _____________________

If yes, by whom _________ Spouse’s net income (week) _______________

5. Number of children living in home: __________ Ages __________

6. Dependents (other than spouse or children) in home, names, relationship, amount contributed

to their support ______________________

7. Do you own a motor vehicle? ____ Year and model __________

How much do you owe on it? ______________________________

8. Do you own a home? _______ Value ________How much do you owe on it? __________

9. Amount of house payment or rent payment each month _____________

10. List checking or savings accounts or other deposits with any bank or financial institution and

the amount of deposits:

_________________________________________________________________________

11. List other assets or property, including real estate, jewelry, notes, bonds or stocks

_________________________________________________________________________

12. List indebtedness and amount of payments

_________________________________________________________________________

13. List any extraordinary living expenses and amount (such as regularly occurring medical

expenses) __________________________________________________________________

14. Child support payable under any court order _____________________

15. Do you understand that whether you are convicted or acquitted ______ County may seek

reimbursement of attorney’s fees paid for you if you become financially able to pay or reimburse

the county but refuse to do so? ____________________________

I have read (had read to me) the above questions and answers and they are correct and true.

The undersigned swears that the information given herein is true and correct and understands that

a false answer to any item may result in a charge of perjury.

The ______ day of _________, 20__.

_________________________

Defendant’s Signature

Sworn to and subscribed before me this ______ day of ____________, 20__.

__________________________________

Notary Public

My Commission Expires _______

ORDER

Having considered the above matter, it is the finding of this court that the above-named

defendant is/is not indigent under criteria of the Georgia Criminal Justice Act and appropriate

court rules and is/is not entitled to have appointed counsel.

It is ordered that the clerk, panel administrator, or court administrator assign an attorney

practicing in this county to represent the defendant in the above case.

Let the defendant and the assigned attorney be notified hereof and furnished a copy of this

application and order.

This ______ day of ___________, 20__.

______________________

Superior Court Judge

_________ Judicial Circuit