Use this form if you are law enforcement, a physician, or other qualified person to certify personal observation of the evaluee or the evaluee’s behavior and based on the observation or other information have reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety to themselves or others.

FORM NOT EFFECTIVE UNTIL 10.01.2026

Use this form if you are a forfeiting authority in possession of seized monies of a defendant in which the property is alleged to be associated with criminal activity and presumed to be subject to forfeiture.

For use with forms MDJ-004AG, MDJ-004C, and MDJ-004GI.

This is a generic continuation sheet that may be used when filing a form that requires additional space.

Request for Reasonable Accommodation for Person with Disability

Request for Waiver of Costs

Request to Shield Address/Telephone Number/E-mail Address in a Criminal Case Record

Request for Final Waiver of Open Costs

Request For Spoken Language Interpreter

Use this form to apply for a Public Defender to represent you in a criminal or traffic case that carries a penalty of incarceration, and you cannot afford an attorney.

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Note: MDJ-004GI must be accompanied by MDJ-010 (Confidentiality Notice)

BROCHURE NOT EFFECTIVE UNTIL 10.01.2026

This form must accompany the DC-099 - Application for Representation by OPD, which gives the Office of the District Court Commissioner access to review certain confidential information (including benefits information and wages earned) in determine if you are eligible for representation by the Office of the Public Defender.