Court Appointed Attorney Application Form
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1
2STATE OF SOUTH DAKOTA)
IN CIRCUIT COURT
:SS
COUNTY OF MINNEHAHA )
SECOND JUDICIAL CIRCUIT
S
S
D
TATE OF
OUTH
AKOTA
,
Plaintiff,
CR. ______________
A
F
vs.
PPLICATION
OR
C
-A
A
OURT
PPOINTED
TTORNEY
(criminal)
Out of Custody
_______________________________,
In Custody
,
[Print Name]
Defendant
Date of Birth ____________________
[Check appropriate box]
Bond Amount $ ________________
I have been charged with the crimes of: _____________________________________________________,
which is a [check one], Felony Misdemeanor.
I swear upon my oath and under penalty of law that the following is true.
1.
I am financially unable to hire an attorney to represent me in my defense.
2.
My current address is:__________________________________________________________
My current email address is:_____________________________________________________
3.
My current home telephone number is:(_______) __________________My current cell phone
number is(_______) __________________ My lawyer can/cannot text this cell phone. (circle one)
Employed
Unemployed
Self-Employed
4.
I am currently:
Employer’s name: __________________________________________
5.
6.
(If employed or self-employed) my current monthly take-home pay averages about $ ___________
(If unemployed) I have income from disability insurance benefits
retirement that
7.
averages $ ________________ per _____________________.
8.
I receive child support and/or alimony payments totaling $ ________________ per month.
9.
My total income before deductions for last year was about $ ________________
10.
Including myself, I have the following number of dependents that rely upon me for support: _____
I have
have not tried to hire my own attorney. (Names of attorneys I have contacted are
11.
listed here): _____________________________________________________________________
12.
The annual income of my spouse is estimated as $ ________________
13.
The following amounts accurately reflect my current assets and debts:
ASSETS
Cash ………………………………………….………….…
a.
$ ________________
Money in bank accounts…………………………………...
b.
$ ________________
c.
Money owed to me by others………………………..….….
$ ________________
Money in investments (stock, bonds, savings bonds)……...
d.
$ ________________
Real Estate (houses and land owned by me) ………………
e.
$ ________________
Motor vehicles (cars, trucks, motorcycles)………………....
f.
$ ________________
Household goods …………………………………………...
g.
$ ________________
Jewelry ………………………………………..……..……..
h.
$ ________________
Other personal property (tools, sporting equipment, etc.)….
i.
$ ________________
……….
T
$ ________________
OTAL ASSETS
DEBTS
Total of money owed, including interest, on real estate…….. $ ________________
a.
b.
Total of money owed, including interest, on motor vehicles... $ ________________
c.
Total of loans owed to banks, payday loan companies, etc....
$ ________________
Total outstanding debts to doctors and hospitals……………
d.
$ ________________
Total of credit card debt …………………………………….
e.
$ ________________
f.
Total of loans owed to other people, not including family....
$ ________________
Total of loans owed to family members………………….....
g.
$ ________________
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