706-444-4444

Criminal Defense Form

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How did you hear about our firm?

The person who needs representation is? *

Me

Someone else

Legal First Name of Client *

Legal Last Name *

Legal Middle Name

Suffix : Jr., Sr., I , II, III.....

Nick Name

Street Address *

City *

State *

Zip Code *

Home Phone *

Mobile Phone *

Work Phone

Email Address

How long have you lived in the Augusta area?

Date of Birth * +

Social Security Number *

Driver's License Number

State of Driver's License

Marital Status of client *

Married

Single

Separated Separated

Do you have children? *

Yes

No

Who will be responsible for paying for your representation? *

How will you pay for your legal representation

Information of Person Filling Out Form If Different Than The Above

Name *

Relationship *

Street Address

City

State

Zip Code

Home Phone

Mobile Phone *

Work Phone

Spouse and Children and Emergency Contact

Name (Spouse) *

Street Address

City

State

Zip Code

Home Phone

Work Phone

Childs First and last Name *

Child's age *

Childs First and last Name

Child's age

Childs First and last Name

Child's age

List the names and ages of any additional children here *

Name (Emergency Contact 1) List a person who can always contact you *

Street Address *

City *

State *

Mobile Phone *

Email *

Name (Emergency Contact 2) List a person who can always contact you

Street Address

City

State

Mobile Phone

Email

Education

How far did you go in school?

Name of high school?

Name of college or technical school?

Employment

Were you employed at the time of arrest? *

No

Yes

Are you currently employed *

Yes

No

Occupation?

Employer Name

How long have you worked for your current employer? *

Employer Address

Name of immediate supervisor

Take home pay and how often paid

Previous Employer Name

What was the time period you worked for your previous employer? *

Ask if they have ever been treated for it or attended rehab/counseling for *

If tested today, you would you test clean or positive for *

Prior Criminal Record

Please list all offenses for which you have been either arrested or convicted (including juvenile offenses); give the date of arrest or conviction, the disposition and the court (Include any first offender plea) *

Are you on PROBATION at this time? *

Yes

No

N/A

If so, then please list the name and address of the person to whom you report

For what offense(s) are you on probation? *

Are you on PAROLE at this time? *

Yes

No

N/A

If so, then please list the name and address of the person to whom you report

For what offense(s) are you on parole? *

Current Offense Information

Date of current arrest * +

Day of Arrest: *

Time of arrest *

Location of Arrest *

Officer at the scene *

Did you give a statement? *

Yes

No

If so, oral or written?

Oral

Written

Name of Detective(s)

Were you searched? *

Yes

No

Was your property searched? *

Yes

No

Were you read your Miranda rights? *

Yes

No

YOUR SIDE OF THE STORY: Please tell me what caused you to be arrested and what you are accused of doing *

WITNESSES: Please list the names, addresses and phone numbers of ALL witnesses that you want to testify for you at trial, including any character witnesses (Use one line per witness, use the plus to add more lines as needed): * 🛈

+-

This is acknowledgement that submitting this form does not in any way bind this firm to represent you. Until this matter is accepted by a member of the firm, we will not be able to undertake any representation. *

I Agree

Submitted Date:

Payment Options

Would you like to pay your $100 consultation fee now? *

Yes

No

Name on Card

Zip Code

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

Security Code