Public Defender Client Questionnaire

Client Questionnaire
PLEASE COMPLETE THIS FORM
1. You should provide your contact information, specifically your email and phone number directly to the court so they can arrange for your first appearance.
2. If you can afford an attorney, you should hire one as soon as possible.
3. If you cannot afford an attorney, please fill out this form.
Name*

First NameLast Name
Home address where you receive mail (with apartment number)*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Alternate Phone Number*
Please enter a valid phone number.
Email Address
Required to receive a confirmation upon completing this form.
Age*
Date of Birth*

MonthDayYear
Date
Race*
Gender*
Marital Status*

SingleMarriedDivorcedLive in partnerWidow
Do you have children?*

YesNo
How many children do you have?*
List each age separated by a comma:*
Do they live with you?*

YesNo
What is your native (first) language?*
Do you need an interpreter for court?*

YesNo
If yes, what Language*
Who do you live with? Add rows as needed.*
Name and relationship of local family members. Add rows as needed.*
Who do you live with? Add rows as needed.*
Name and relationship of local family members. Add rows as needed.*
Court Name*
Next Court Date and Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Immigration
Were you born in the United States?*

YesNo
Are you a United States Citizen?*

YesNo
What is your primary country of citizenship?*
What year did you move to the United States?*
Number only
Are you currently in the United States legally?*

YesNo
Education
Are you currently enrolled as a student?*

YesNo
If yes, what is the name of the school?
What grade/level?
Did you graduate high school?*

YesNo
Did you graduate College?*

YesNo
How old were you when you last attended school?*
Military
Are you currently in the military?

YesNo
Were you formerly in the military?

YesNo
What branch of the military did you serve in?
What dates did you serve in the military?
If former, did you receive an Honorable or Dishonorable Discharge?

HonorableDishonorable
Current Matters
Aside from the charge for which you are applying right now, do you have any other open criminal charges in any other court?*

YesNo
If yes, what are the charges?
What court?
Are you currently on Probation?*

YesNo
If yes, from what court?
Are you currently on Parole?*

YesNo
History of Issues
Please answer yes or no to each item below:
Do you have a prior history of drug or alcohol abuse?*

YesNo
If yes, what drug?
Are you currently in treatment?

YesNo
Have you previously been in treatment?

YesNo
When and where are/have you been in treatment?
Do you have a prior history of medical or mental health issue?

YesNo
If yes, please explain:
Are you currently in treatment?

YesNo
Have you previously been in treatment?

YesNo
When and where are/have you been in treatment?
Employment/Sources of Income
Are you currently employed?*

YesNo
If not employed, how long have you been unemployed?
If not employed, Are you receiving unemployment assistance?

YesNo
If yes, what is your occupation?
Who do you work for (name of company or person)?
What type of business do they do?
What type of work do you do?
What is the address/town where you work?
How long have you worked there?
What is your weekly income?
What is your spouse/domestic partner's weekly income?
How much do you receive from the following each week?
SSI/SSD
Public Assistance
Alimony/Maintenance/Child Support
Investments
Other
Assets
How much is in your checking account right now?
How much is in your savings account right now?
How much is in any investment account right now?
Do you own a home?

YesNo
If yes, how much equity is in the home?
Do you own a car?*

YesNo
If yes, what is the current value?
What is the year/make/model?
What is the value of any stocks or bonds that you own?
What is the value of any other property/investment/etc that you own?
Liabilities

Including total of yours and any spouse/domestic partner.
How much do you pay a month for the following:
Mortgage or Rent
Utilities Bill (Include Gas/Electric/Water)
Phone/Mobile Phone Bill
Car loan or lease
Child support
Medical/dental/legal fees
Other monthly expenses
If other, explain
Defense

There are essential time limits relevant to your case which require you and/or your attorney to disclose certain information to the prosecution. Failure to provide the below information may result in a court ruling that your attorney may not present certain evidence in your case.
Are there any witnesses to this incident that would be helpful to your case?

YesNo
If yes please provide the following information.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Were you somewhere else when this crime was allegedly committed?

YesNo
If yes, where were you at that date/time?
Do you have any audio recordings, videos, letters, text messages, emails, or photographs that would be helpful to your case?

YesNo
If yes, describe.
Criminal Charges
How did you go to court (choose one):

Arrested and brought to court by police officer orGiven Appearance Ticket by police officer orReceived notice in the mail to appear in court
Did you post bail or bond?

BailBondNone
If bail or bond, how much?
Explain briefly what happened that led to you being charged:*
AFFIDAVIT OF INDIGENCY / AUTHORIZATIONS:

State of New York

County of Rockland

The undersigned, being duly sworn, deposes and says as follows, under the penalties of perjury:
1. That all statements made herein on this form and the information provided in my intake interview are true and were so made to indicate to the Public Defender’s Office that I am truly an indigent person unable to afford private counsel. I hereby request and retain the Public Defender’s Office of Rockland County to represent me on the criminal charges I have listed.
2. That I have been warned that this is a sworn statement and that I may be prosecuted for any false statement I have given to the Public Defender’s Office in order to determine my eligibility as an indigent person.
3. That I hereby authorize the Rockland County Public Defender’s Office, in their discretion, to disclose and discuss the following with the Office of the District Attorney or other prosecutor, any judge or court, immigration attorney, expert witness or any treatment provider for the benefit of my defense or in negotiation of a plea: The facts and circumstances of my case; Personal and other background provided by me; Any medical records, mental health records or other records provided by me or obtained with my authorization; My criminal history and pending charges against me.
4. I also authorize the Rockland County Public Defender’s Office to disclose and discuss my legal matters and the facts and circumstances of my case with the following individuals:
Please enter Name, Relationship and Phone Number for each individual. Add rows as needed.*
1. That my file will be maintained by the Public Defender’s Office for a period of seven (7) years after the matter is closed and destroyed thereafter without further notice.
2. That it is my responsibility to maintain contact with the Public Defender’s Office to assist in the defense of my case and to immediately update the office with any change in contact information.
Signature*

Clear
Date*

MonthDayYear
Date
Reply to Email - Spam filter exception - do not change.
example@example.com
Should be Empty:

Client Questionnaire

Immigration

Education

Military

Current Matters

History of Issues

Employment/Sources of Income

Assets

Liabilities

Defense

If yes please provide the following information.

Criminal Charges