Ujs 224 Application For Court Appointed Counsel Form
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1UJS 224 (10/2011)
STATE OF SOUTH DAKOTA )
IN CIRCUIT COURT
) SS
____________JUDICIAL COURT
COUNTY OF ______________ )
STATE OF SOUTH DAKOTA
)
)
APPLICATION
VS
)
)
FOR
_______________________________________ )
COURT – APPOINTED COUNSEL
(print your name)
)
I have been charged with the crime(s) of _______________________________________________________________________ which is
a (check one)
_____ FELONY _____ MISDEMEANOR under South Dakota law. 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 ________________________________________________; my email 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 the previous year ______ was $_______________.
(8)
My total year-to-date income before deductions for the current year ______ is $______________.
(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.)………………………………………………….. $___________
I owe ____________________________________ this amount………………………………….. $___________
b. LOANS:
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 if I have a court-appointed lawyer, his fees are loaned and not given to me. I will be asked to repay the county,
If I am able, and a lien will be filed against my property to insure payment.
Dated this ________ day of _________________, 20 ______.
X_______________________________________, Defendant
Subscribed and sworn to before me this______________day of ___________________, 20________.
My commission expires:_____________________
___________________________________________________
(Magistrate, Circuit Judge, Notary)
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