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Defendant Name(Required)

First Last

Date of Birth

Contact person (if you are not defendant)

Defendant Phone Number(Required)

Defendant Email Address

Defendant Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Docket Number

Court where case was resolved

Are you on probation?

Plea or Trial attorney name

Client comments or concerns

How many people live in your household?

Do you receive Transitional Aid to families with Dependent Children(TAFDC)?

Do you receive Emergency Aid to the Elderly, Disabled or Children(EAEDC)?

Do you receive Massachusetts Veterans Benefits Programs?

Do you receive Medicaid (MassHealth), Supplemental Security Income(SSI)?

Are you currently employed full-time?

Were you represented by court-appointed counsel within the last three years (in your OUI or any other matter)?