Application For A Public Defender - State Of Minnesota Page 3
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6Additional Sources of Income: ______________________________________________________________________
DEPENDENTS
15. How many dependent children do you have? _____
a) How many dependent children live with you _____? Please list.
Dependent(s) Name
Age
Dependent(s) Name
Age
Additional Dependents (Not living with you):_________________________________________________________
PROPERTY AND ASSETS
16. If you and or your spouse own or are buying any property listed below, fill in the information about that property
on the rest of the line.
Make and
Property Owned or Buying
Model
Present Value
Amount You Owe On It
House or Mobile Home
$
$
Automobile(s)
$
$
Other vehicles
$
$
Recreational vehicles or boats
$
$
Other real estate
$
$
Other property(List):
1)
$
$
2)
$
$
3)
$
$
4)
$
$
List
Additional:_____________________
_________________________________
$
$
17. If you, and/or your spouse, own any other assets please fill in the information about that asset on the rest of the
line.
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Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
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