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2. Personal Information
4. First Name*
5. Middle Initial
6. Last Name*
8. Were you born in the US?*

   1. Yes
   2. No
9. If no, where were you born?*
11. Is English your first language?*
    -- Select One --YesNo
13. Preferred language*

    Please type your preferred language

15. Mailing Address*
17. City*
18. State*
19. Zip*
21. Email Address
22. Phone*
23. Accept Text?*

    1. Yes
    2. No
24. Accept Email?

    1. Yes
    2. No
26. Gender

    1. Male
    2. Female
27. Are you a Veteran?

    1. Yes
    2. No
29. Do you currently receive Public Assistance?*

    1. Yes
    2. No
30. Do you currently receive SSI/SSD?*

    1. Yes
    2. No
32. If so, where?
34. Name, relationship, and age of members in household:*
    Please write "n/a" if you are only household member
38. Court Information
40. Type of Application*
    -- Select One --Criminal ChargesViolation of ProbationSORATreatment CourtChild Support ViolationCustody/VisitationFamily OffenseNeglect/AbuseSupport Modification (Do Not Represent)
44. Employment/Expenses Information
    If you are working, you must submit your most recent paycheck stub(s) in order to be considered for Public Defender representation.
46. EMPLOYMENT
48. Are you currently in school?
    -- Select One --YesNo

    High school or college, part time or full time
49. Are you currently working?*

    1. Yes
    2. No
    3. Retired
50. If not currently employed, how are you paying daily expenses?*
52. Hours Per Week:
54. Approximate Monthly Living Expenses:

    Rent, utilities, child support, etc. 

58. Please submit this form and supply any court documents and proof of income as soon as possible in order for your application to be processed. Our contact information is as follows:
60. Livingston County Public Defender 6 Court Street, Room 109 Geneseo, NY 14454 Phone: (585) 243-7028 Fax: (585) 243-7193 Email: lcpd@livingstoncountyny.gov
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62. Submit

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