Application For A Public Defender - State Of Minnesota
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6State 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
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of a live-in girlfriend/boyfriend.
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?
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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.
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Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
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