Voucher Request Form

IF YOU NEED A REPLACEMENT VOUCHER OR WERE ASSIGNED IN COURT AND HAVE NOT YET RECEIVED A VOUCHER

Please fill in the fields below and provide further information you deem necessary in the "COMMENTS" area. Please fill out all dates in the format "mm/dd/yy" We will forward the voucher to you. You must always fill out the Attorney Name field. For replacement of a voucher for an existing ACP assigned case fill out only those fields marked with an *. For all other cases fill out all fields.

Attorney Name *

ACP File# (for replacement voucher) *

Client Last Name *

Client First Name *

Client Middle Name

Client Date of Birth

Client Street Address

Client City, State & Zip

Assignment Judge

Docket # (Family Court Only)

Assignment Date

Arrest Date

Arraign Date

Most Serious Charge

Nature of Conflict

722-D Contribution

Yes

Comments

CAPTCHA

This question is to prevent automated spam submissions.

  ____    ____    _____         _            
 |  _ \  |___ \  |  ___|  ___  | | __   __ _ 
 | | | |   __) | | |_    / __| | |/ /  / _` |
 | |_| |  / __/  |  _|   \__ \ |   <  | (_| |
 |____/  |_____| |_|     |___/ |_|\_\  \__, |
                                       |___/

Enter the code above *

Enter the code depicted in ASCII art style.

print this page email this page back to top

About MonroeCounty.gov · Accessibility and Standards · RSS News Feed
Disclaimer and Privacy Policy · Non-Discrimination Policy

QUICK LINKS

Monroe County, NY

Voucher Request Form

IF YOU NEED A REPLACEMENT VOUCHER OR WERE ASSIGNED IN COURT AND HAVE NOT YET RECEIVED A VOUCHER