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ION FOR COUNSEL (Defense of Indigency Act, Form No.2) CRIMINAL CHARGING DOCUMENT NO. NAME OF APPLICANT ADDRESS TELEPHONE NUMBER(S) DATE OF BIRTH SOCIAL SECURITY NO. NAMES OF CO-DEFENDANTS 1. Are you presently employed? Yes No a. If yes , state the amount of your salary or wages per month, and give the name and address of your employer. SALARY OR WAGES PER MONTH NAME AND ADDRESS OF EMPLOYER If no , state the name and address of last employment, date of termination of employment,.

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