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Assigned Counsel Reimbursement Forms - Ohio
| Assigned Counsel Reimbursement Forms Form. This is a Ohio form and can be used in General Tuscarawas County (Court Of Common Pleas) . |
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SAMPLE RECOUPMENT POLICY _____________________ County Indigent Defense Fee/Cost Recoupment Policy 1. The Court shall review each defendants indigent status and determine if recovery of assigned counsel fees or public defender costs is appropriate. The Cour t may waive the fees if it is determined that the imposition of such would result in an undue hardship on the client. 2. The Court may order further income verification to determine eligibility . The income verification fee shall be $25.00, subject to waiver by the Court in the case of undue hardship. 3. The Court shall order when the reimbursement fee shall be due. 4. The Court may request that the defendant sign an agreement regarding the recoupment amount. The agreement form to be used is attached to this po licy. 5. Persons shall pay according to the following schedule, determined by the highest degree of offense charged: Felonies $100.00 Misdemeanors $ 50.00 Abuse/Dependency/Neglect Cases $100.00 Other Juvenile Cases $ 50.00 6. Payments shall be remitted to the county Clerk of Courts, payable by cer tified check or money order (cash not accepted) made payable to the County Treasure r. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 AGREEMENT TO REIMBURSE LEGAL COSTS/FEES I, ____________________________hereby request counsel to represent my interests in ____________________________________________________ Court; Case No(s). __________________________________________________________ _. I certify that the financial information contained in the Financial Disc losure Statement attached hereto is true and accurate to the best of my knowled ge. I further certify that I have been unable to retain private counsel and hereby request the ______________ County Public Defender or assigned counsel to represent my interests herein. I agree that I may reasonably be expected to reimburse _____________ Cou nty for some part of the costs of representation and, as consideration for s aid representation. I hereby agree to pay $___________ by certified check o r money order payable to the ______________County Treasurer as reimbursement for the c osts of the legal services rendered to me. I agree said amount is reasonable based on my income and/or assets and f urther agree said amount shall be paid as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I also understand that if it is determined by the ______________ County Public Defender, State Public Defender, assigned counsel or by the Court, that I was not entitled to the legal representation provided to me, I may be required t o reimburse the County for the full costs thereof. Date:__________________________ Signed: ___________________________ Witness: ___________________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 SAMPLE RESOLUTION Whereas, the Office of the Ohio Public Defender has by Rule OAC 120-1-03 adopted regulations for the appointment of counsel for the indigent; and , Whereas, pursuant to this rule, the Board of County Commissioners needs to adopt a verification procedure and a plan to recoup all or part of the c ost of counsel for persons who meet certain income guidelines. It is hereby resolved that: The Courts of this county shall make the appointment of counsel, either private assigned counsel or the County Public Defender, in accordance with the r ules established by the Ohio Public Defender Commission and the State Public Defender to enable this county to receive reimbursement from the state for a part of the indigent defense costs. The Courts of this county assigning indigent defense counsel shall, in accordance with OAC 120-1-03, order that a part or all of counsel fees be repaid to the County where appointment is made and the defendant falls into the income guidelines set forth in the rule (currently 125 percent to 187.5 percent of the po verty threshold). Payments shall be made pursuant to the _______________ County Indigent Defense Fee/Cost Recoupment Policy, a copy of which is hereby attached t o this resolution. This resolution shall be effective for all cases with an appointment dat e of ______________ or later. Board of County Commissioners ______________________________ ______________________________ ______________________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 VERIFICATION OF INCOME AUTHORIZATION FOR RELEASE OF INFORMATION TO WHOM IT MAY CONCERN: I am unable to provide all necessary background information pertinent to my case now pending in _________________ County. I, therefore, authorize and direct the ______ ___________ COUNTY PUBLIC DEFENDER or my ASSIGNED COUNSEL __________________________to cont act the (attorney name) following sources for additional information: _____Employer _____Internal Revenue Service _____Financial Institutions _____Physicians & Medical Institutions _____Insurance Companies _____Any agency of the State of Ohio _____Law Enforcement Agencies _____Any agency of ______________ County _____Military _____Schools _____Employers _____Correctional Facilities _____Veterans Administration _____Other _____Social Security Administration _____Payee/Trustee/Guardian I hereby authorize and direct those sources checked above to release any and all information requested by the agents of the County Public Defender or my above named assigned counsel. It is my understanding that all information concerning me will be regard ed as confidential. This document has been read by me/to me and its purpose explained to my satis faction. NAME: _________________________________ Address: _________________________________ _________________________________ Phone: _________________________________ DOB: ___________ SS# ________________ Signature: ________________________________ Witnessed: ________________________________ Date: ________________________________ Information requested: ________________________________________________________________________ ________ ________________________________________________________________________ _____ Return information to American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 5 MONTHLY RECOUPMENT REPORT for ________________ County Funds Collected from Indigent Clients/State Reimbursement _____________ (Date of Report) Date Mont
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