Application For A Public Defender - State Of Minnesota Page 4
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6Assets
Value
Cash on hand
$
Balance in all bank accounts
$
Total tax refund(s) coming
$
Stocks, bonds, IRA's other annuities
$
Retirement accounts
$
Other assets: Please list-
$
1)
$
2)
$
3)
$
List additional:_____________________
_________________________________ $
18. Have you transferred ownership in any property since the date of your alleged offense? YES_____ NO_____
a) If you answered YES to question 18 what was the property and its value? _________________________________
_________________________________________________________________________________________________
EXPENSES
19. Please list your monthly expenses.
Your Monthly Expenses
Amount Spent Monthly
Housing: Rent___ Mortgage_____
$
Groceries
$
Utilities (heat, lights, water, phone, etc.)
$
Car/Vehicle payment
$
Other Transportation Costs (bus, gas, etc.)
$
Insurance (life, house, auto etc.)
$
Employment Expenses (tools, fees, dues)
$
Education Expenses (tuition, books)
$
Medical Expenses
$
Child Care
$
Child Support and Alimony
$
Student or Personal Loans
$
Other:
$
1)
$
2)
$
3)
$
4)
$
Additional:__________________________
___________________________________ $
Total Monthly Expenses
$
20. Do you have any special circumstances that you feel should be considered by the Court in deciding whether to
appoint a public defender? YES____ NO_____ If YES, explain________________________________________________
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Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
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