Application For A Public Defender - State Of Minnesota Page 2
Download a blank fillable Application For A Public Defender - State Of Minnesota in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For A Public Defender - State Of Minnesota with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6SSI_____ 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)
Amount
$
$
$
$
2
Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business