State of Minnesota Application for a Public Defender County: ____________ Court File No.:____________ Judicial District:____________ Level of Offense: Misdemeanor_____ Gross Misd._____ Felony_____ Probation Violation_____ Other_____ Name: _____________________________ Date of Birth: _______________ SSN_____________ Permanent Address: ________________________________________________________________________ Temporary Address: ________________________________________________________________________ Home Phone: ___________ Work Phone: ___________ Cell Phone: ____________ e-mail________________ � � � � � � � � If you need help, do not understand a question, or have difficulty reading ask court personnel for help, or refer to the instructions below. Only people who cannot afford an attorney are eligible to have a public defender represent them. The judge may ask you to explain, under oath, any of your answers, or any questions you leave blank. Even if you are found eligible for a public defender, you may be required to pay some amount toward the cost of your representation. If you are eligible for a public defender the Court may impose a $75 co-payment separate from any other reimbursement that is ordered. If you fail to pay the court-ordered reimbursement or co-payment, the Court may refer your case to the Minnesota Department of Revenue for collection of the unpaid amount. This could affect any Minnesota income tax refund, property tax refund, or rent credit that you may be entitled to. You have a continuing duty to disclose to the court any changes in your financial circumstances. I understand that the judge may ask a broad range of questions about my financial circumstances to determine whether I am financially unable to afford counsel, including questions about the income and assets of a live-in girlfriend/boyfriend. 1 READ THIS BEFORE YOU FILL IN THE FORM Instructions for completing the questions on this form: A. ADDRESS: where you are staying, if you are at a temporary address (for instance, if you are prohibited from returning to your residence), and also the complete address of where you get your mail. B. PHONE NUMBERS, E-MAIL: Your attorney needs to be able to contact you at all times, especially by phone. You should include any number that you can be contacted at, including message phones. If you are not the owner of a number, please include the name of the person who is. 1. MEANS TESTED PUBLIC ASSISTANCE: List only for you, and any of your legal dependents who live with you; specify type of assistance received, who receives it, and the amount. A means tested benefit (including cash, medical, housing, and food assistance and social services) is one in which the eligibility for benefits, or the amount of such benefits, or both are determined on the basis of income, resources, or financial need. 7. GROSS INCOME: Income before taxes and other deductions are taken out. 1 and 15. DEPENDENTS: Someone that you are otherwise legally responsible for, generally a biological, step or legally adopted child age 18 or younger, but may also include a disabled family member living with you. 14. OTHER INCOME OR MEANS OF SUPPORT: Such as from a parent, court settlement or a business you own. If so, indicate that here and provide a description of the income. 1 1 Created by the State Public Defender, August 2012 (Minn. Stat. � 611.17(b)). Under Minnesota case law, State v. Jones, 772 NW2nd 496 (Minn. 2009), the Court may consider the income and assets of a spouse or live in girlfriend/boyfriend in determining eligibility for a public defender. American LegalNet, Inc. www.FormsWorkFlow.com 17. OTHER ASSETS: Include anything that can be sold, pawned or pledged for cash, such as all vehicles, boats, snowmobiles, motorcycles, ATVs, bonds, real estate or real property not previously listed, etc. Please provide specific information here, including a description of the asset, make/model/value and the amount of any loan on the asset. 19. HOUSING COSTS YOU PAY: If you own your home, please be sure to include what your home is worth and the amount remaining on your loan. If you share rent, list only the portion you pay. PLEASE PRINT YOUR ANSWERS 1. Do you or a dependent who lives with you receive any form of means tested public assistance? YES____ NO____ a) If you answered YES what benefit is received? SSI_____ Food Stamps_____ TANF_____ General Assistance____ Medical Assistance____ MFIP____ Minnesota Supplemental/Emergency Assistance (MSA) ____ Other _____ (Please List) __________________________________ b) If a dependent living with you receives means tested benefits, how are they related to you? ___________________________________________________________________________ 2. Have two attorneys refused to handle your case because you could not afford their fees? YES_____ NO_____ a) If you answered YES, what were the fees: 1) $ ____________, 2) $ _____________ b) If you answered YES, please give their names: 1) ______________________, 2) ______________________ c) Were these lawyers on a list given to you by the Court? YES_____ NO_____ EMPLOYMENT and INCOME 3. Are you currently working? YES_____ NO_____ 4. What is your employer's name, address and telephone number? Name: _____________________________ Address: __________________________________ Phone: ______________ 5. What type of work do you do? ____________________ How long ____________? 6. Your wage: $_______/hourly Hours worked per week: _______ 7. What is your total monthly gross income? $___________ Net monthly Income (take home) $__________ 8. What is your marital status? MARRIED____ SINGLE____ SEPARATED____ DIVORCED_____ 9. What is your spouse's name? ________________________________ 10. Is your spouse working? YES_____ NO_____ 11. What is your spouse's employer's name, address and telephone number? Name: ______________________________ Address: _________________________________ Phone: ______________ What types of work does your spouse do? ________________________ How long________? 12. Spouse's wage: $_______/hourly Hours worked per week: _______ 13. What is your spouse's monthly gross income? $_____ Net income (take home) $_________ 14. List all other income (money) received by you and or your spouse from all other sources. Source of Income (Please List) $ $ $ $ Additional Sources of Income: ______________________________________________________________________ DEPENDENTS 15. How many dependent children do you have? _____ 2 Created by the State