Approved, SCAO
Original - Court 1st copy - Defendant 2nd copy - Appointed attorney
STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT
ORI
REQUEST FOR COURT-APPOINTED ATTORNEY AND ORDER
CASE NO.
Court address
Court telephone no.
MI-
The State of Michigan THE PEOPLE OF v
Defendant name, address, and telephone no.
CTN
SID
DOB
REQUEST The defendant requests a court-appointed attorney and submits the following information. 1. CHARGE Next hearing:
Date
Misdemeanor Felony Paternity Bond posted
Bail amount: $ 4. INCOME Employer name and address
2. RESIDENCE Rent Own 3. MARITAL STATUS Single Divorced Married Separated
Length of employment
Live with parents Room/Board Dependents:
Number
Average take-home pay $ weekly monthly
Other Income State monthly amount and source (DSS, VA, rent, pensions, spouse, unemployment, etc.).
every two weeks
5. ASSETS*
State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc.
6. OBLIGATIONS*
Itemize monthly rent, installment payments, mortgage payments, child support, etc.
7. CONTRIBUTION TOWARD ATTORNEY COSTS I understand that I may be required to contribute to the cost of an attorney. Date:
*Use reverse side for additional information/comments.
Signature:
ORDER 8.
Name Bar no.
is appointed to represent the defendant.
9. The petition is denied because:
District Court Endorsement
Date Judge MC 222 (3/09)
(felony cases only)
Date Bar no. Judge Bar no. MCR 6.005(B), MCR 6.610(D),(G)
REQUEST FOR COURT-APPOINTED ATTORNEY AND ORDER