Date

First Name

Full address

Telephone

Madam, Mr. President of the Order

Office Commissions Service

Full address

Madam, Mr. Bâtonnier,

I am convened on ..................................................................................................................................................

in front (tick the corresponding box):

□ CRIMINAL COURT

□ POLICE COURT

□ INVESTIGATING JUDGE

□ COURT OF ASSIZE OR CRIMINAL COURT

□ FAMILY JUDGE (hearing of a minor child)

□ JUDGE FOR CHILDREN

□ GUARDIANSHIP

□ JUDICIAL TRIBUNAL

□ COMMUNITY COURT

□ OTHER: ........................................................................................................................................................................................................................................................................................................................

I would ask you to please appoint me a court-appointed lawyer for this hearing.

I have noted that:

- if i meet the conditions, the services of this lawyer will be covered by legal aid.

- if I cannot receive legal aid, the lawyer will ask me for payment of his fees to be fixed under an agreement.

Attached is a copy of my summons (must be attached).

Signature