Public Defender Intake Form

Cuyahoga County Office of the Public Defender, Municipal Division
Courthouse Square
310 Lakeside Avenue, Suite 400
Cleveland OH 44113
216.443.7223

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Today's Date

Date of Birth

Last Name

Phone Number

First Name

Soc. Sec. No. (last four)

Address 1

Address 2

City

State

Zip Code

Email Address

Charge(s) (if known):

Judge (if known):

Emergency Contact

Case Number(s) (if known):

Court Date (if known):

If you don't have an open case, what are you applying for?

FINANCIAL INFORMATION

Are you working?

Yes
No

If yes, name of employer?

Monthly Income

Do you receive any of the following? (please click all that apply)

SSI:SSD:Medicaid:Veterans' BenefitsFood Stamps:

Type the code from the image