2. APPLICATION FOR LEGAL REPRESENTATION - CORTLAND COUNTY OFFICE OF ASSIGNED COUNSEL

   Cortland County Office Building - Suite B27, 60 Central Avenue Cortland, New York 13045 Phone: (607) 428-5459 / Fax (607) 428-5458

3. 
4. Revised August 2023
6. Name*
7. Last 4 Numbers of your Social Security Number*
9. Applicant Formerly Known as or Other Names:
11. Email Address*
12. Date of Birth*
14. Address*
16. City*
17. State*
18. Zip Code*
20. Phone Number*
21. Alternative Phone Number
23. Mailing Address (if different)
25. City
26. State
27. Zip Code
29. Please Check One*

    1. Criminal

    1. Family
31. Which Criminal Court:

    1. Cortland City
    2. Cortlandville Town Court
    3. Cortland County Court

    1. Homer Town Court
    2. IDV Court

    1. Virgil Town Court
    2. Other
33. Define Other Court:
35. Next Court Date and Time of Appearance
37. MUST HAVE FOR FAMILY COURT:
38. File #:
39. Type of Case:
41. Previous or current public defenders or assigned counsel:
43. Co-Defendants/Witnesses
45. NOTICE
    WE ENCOURAGE YOU TO INCLUDE PAPERS/CHARGES
46. Upload Document
48. INCOME INFORMATION (ALL INFORMATION IS CONFIDENTIAL):
50. How many children under the age of 21 living in the house do you support?
52. EMPLOYED?*

    1. Yes
    2. No
53. If yes, where:
55. STUDENT?*

    1. Yes
    2. No
56. Is yes, where:
58. If No to both, how are you supporting yourself:*
60. If employed, how much do you bring home:
61. per
63. Do you receive any of the following need-based public assistance/income?
65. Social Security Disability Income (SSDI); other disability income*

    1. Yes

    1. No
67. Public Assistance, SSI/SSP (need based Social Security)*

    1. Yes

    1. No
69. Food Stamps*

    1. Yes

    1. No
71. Unemployment Insurance Benefits*

    1. Yes

    1. No
73. Worker's Compensation*

    1. Yes

    1. No
75. Vetern's Benefits*

    1. Yes

    1. No
77. Other Need Based Income or Subsidy

    1. Yes

    1. No
79. If yes, what other income/subsidy:
81. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
83. Electronic Signature*
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit Submit and Print

* indicates a required field