Ujs 224a Application For Court Appointed Counsel For Juvenile Form
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1UJS 224A(5/05)
STATE OF SOUTH DAKOTA )
IN CIRCUIT COURT
:SS
JUVENILE DIVISION
COUNTY OF ______________ )
____________JUDICIAL CIRCUIT
________________________________________________________________________________________________________
THE PEOPLE OF THE STATE OF SOUTH
DAKOTA IN THE INTEREST OF,
)
APPLICATION FOR COURT APPOINTED
)
COUNSEL FOR JUVENILE
_______________________________________ )
(print child’s name)
(DOB)
)
Docket #_________
Minor Child and Concerning
)
_______________________________________ ) Parent’s Financial Information_____OR Child’s Financial Information______
_______________________________________)
(Check Appropriate Line)
(print parent or guardian name)
)
Out of custody____ In custody_____
(Check Appropriate Line)
Child has been charged with offense(s) of _______________________________________________________________________. I hereby
swear on oath and under penalty of law that the following is true.
I (HAVE) (HAVE NOT) TRIED TO HIRE MY OWN LAWYER. Who: ____________________________________
.
(1)
I am financially unable to hire a lawyer to represent me in my defense
(2)
My address is _____________________________________________________________________________________
(3)
My telephone number is: _____________________________, my date of birth is ______________________________
(4)
I am (check one) _____ EMPLOYED
_____ UNEMPLOYED
_____ SELF EMPLOYED
(5)
(If employed) my weekly take home pay is: $_______________.
(6)
Retirement, disability, or insurance benefits: $_______________ per _______________.
(7)
My total income before deductions for year ______ was $_______________.
(8)
My total income before deductions for year ______ was $_______________.
(9)
Including myself, I have the following number of dependants: ____________________________________________.
(10)
The following amounts accurately represent my assets and liabilities:
I.
ASSETS(things I own or am buying)
a. CASH (on hand or in banks) ……………………………………………………………………………………….. $ __________
b. ACCOUNTS and NOTES RECEIVABLE (IOU’s and other money payable to me)……………………………… $ __________
c. INVESTMENTS (stocks, bonds, savings bonds, etc)………………………………………………………………. $ __________
d. REAL ESTATE (house, land, tribal lease land, rental property, etc)……………………………………………….. $ __________
e. AUTOMOBILE (S) make, model & year:
____________________________________________________________________________________________ $___________
f. HOUSEHOLD GOODS(furniture, appliances, TV, stereo, etc.)……………………………………………………. $___________
g. OTHER PERSONAL PROPERTY (tools, sports equipment, etc)…………………………………………………. $___________
h. ANY OTHER ASSETS(anything else I could sell or borrow money on)…………………………………………… $___________
TOTAL ASSETS
$___________
II.
LIABILITIES (money that I owe)
a. My regular monthly expenses are: (housing, utilities, food, etc.)………………………………………………….. $___________
b. LOANS:
I owe ____________________________________ this amount………………………………….. $___________
I owe ____________________________________ this amount………………………………….. $___________
I owe ____________________________________ this amount………………………………….. $ __________
TOTAL LIABILITIES
$___________
III.
ANTICIPATED INCOME (money or property you are expecting)
a.
Total monies or income from sale of house or land, alimony, gifts, inheritance, allotments,
Trust funds, lease money, etc……………………………………………………………………………………… $___________
(11)
I understand that pursuant to SDCL 26-7A-32, the child or parents of child may be responsible for re-payment to county for court
appointed attorney fees, if able, and a lien may be filed against their property to insure payment.
Dated this ________ day of _________________, 20 ______.
X ______________________________________, Child
X_______________________________________, Parent
Subscribed and sworn to before me this______________day of ___________________, 20________.
My commission expires:_____________________
___________________________________________________
(Magistrate, Circuit Judge, Notary)
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