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________________ READ THIS BEFORE YOU FILL IN THE FORM If you need help, do not understand a question, or have difficulty reading ask court personnel for help, or refer to the instructions on the last page of this form. 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 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? 1 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. 1 Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)). Rev 7/15 American LegalNet, Inc. www.FormsWorkFlow.com 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) $ $ $ $ 2 Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)). Rev 7/15 American LegalNet, Inc. www.FormsWorkFlow.com Amount Additional Sources of Income: ______________________________________________________________________ DEPENDENTS 15. How many dependent children do you have? _____ a) How many dependent children live with you _____? Please list. Dependent(s) Name Age Dependent(s) Name Age Additional Dependents (Not living with you):_________________________________________________________ PROPERTY AND ASSETS 16. If you and or your spouse own or are buying any property listed below, fill in the information about that property on the rest of the line. Property Owned or Buying House or Mobile Home Automobile(s) Other vehicles Recreational vehicles or boats Other real estate Other property(List): 1) 2) 3) 4) List Additional:_____________________ _________________________________ Make and Model Present Value $ $ $ $ $ $ $ $ $ Amount You Owe On It $ $ $ $ $ $ $ $ $ $ $ 17. If you, and/or your spouse, own any other assets please fill in the information about that asset on the rest of the line. 3 Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)). Rev 7/15 American LegalNet, Inc. www.FormsWorkFlow.com Assets Cash on hand Balance in all bank accounts Total tax refund(s) coming Stocks, bonds, IRA's other annuities Retirement accounts Other assets: Please list1) 2) 3) List additional:_____________________ _________________________________ $ $ $ $ $ $ $ $ $ $ Value 18. Have you transferred ownership in any property since the date of your alleged offense? YES_____ NO_____ a) If you answered YES to question 18 what was the property and its value? _________________________________ _________________________________________________________________________________________________ EXPENSES 19. Please list your monthly expenses. Your Monthly Expenses Housing: Rent___ Mortgage_____ Groceries Utilities (heat, lights, water, phone, etc.) Car/Vehicle payment Other Transportation Costs (bus, gas, etc.) Insurance (life, house, auto etc.) Employment Expenses (tools