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Juvenile Court Project
Services
Resources
Literature
Links
About
Contact Us
Get Help Now
Modified Application for Representation
Step
1
of
4
25%
Juvenile Court Project: Application for Representation
Name
(Required)
First
Initial
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Email Address
Email Address
Confirm Email Address
Inmate No.:
(Required)
Counselor:
First
Last
Pod No.:
Counselor's phone no.:
Correctional Institution:
(Required)
Mailing Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Arrested For (Charges):
(Required)
Defense Attorney
First
Last
Defense Attorney's Telephone No.:
Parole/Probation Ofc.:
First
Last
Parole/Probation Ofc.'s Telephone No.:
Conviction(s) For:
(Required)
Sentence:
(Required)
Date Incarcerated:
(Required)
MM slash DD slash YYYY
Date Minimum Up:
MM slash DD slash YYYY
Date Maximum Up:
MM slash DD slash YYYY
Have you ever been represented by a Parent Advocate before?
No
Yes
Who Represented you?
When were you represented?
MM slash DD slash YYYY
Who was the Judge/ Hearing Officer?
CYF Caseworker
Reg. Ofc.
First
Last
Caseworker’s phone no.
Next hearing date
MM slash DD slash YYYY
Type of Hearing
Judge/Hearing Officer for next hearing
Children
List below all your children under the age of 18.
List
(Required)
First Name
Last Name
Date of Birth
Name of Other Parent
Add
Remove
Contact
List below two people who will always be able to tell us your current address and phone number.
First Contact
Name
(Required)
First
Last
Phone
(Required)
Relationship to You
(Required)
Second Contact
Name
First
Last
Phone
Relationship to You
Consent
(Required)
I accept.
I hereby certify that all the preceding information is true and correct to the best of my knowledge, information, and belief. I hereby request that a parent advocate attorney be assigned to represent me in Allegheny County Juvenile Court dependency proceedings concerning my child(ren). I understand my responsibility to report to my parent advocate attorney any changes in income or household composition that would affect my eligibility for free legal services. I understand my responsibility to immediately inform my parent advocate attorney of any change in my address or phone number. I understand that if I fire my parent advocate attorney, no other Juvenile Court Project parent advocate attorney will be provided to represent me. I understand that in the event I become incapacitated, the Juvenile Court Project will contact my family (adult children, parents, siblings) and any person(s) I have designated in writing, to notify them of the process of obtaining guardianship of my person. I understand that the Juvenile Court Project will file appeals on my behalf only when the Juvenile Court Project determines there is a meritorious legal basis for appealing. I understand that the Juvenile Court Project will retain my client case file for 5 years from the date of case closure and after such time my client case file will be destroyed and unavailable to me.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Eligibility
Eligibile
Ineligibile
PA Assigned
First
Last
Intake By
Intake Date
MM slash DD slash YYYY
