Application For A Public Defender - State Of Minnesota Page 5
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6__________________________________________________________________________________________________
I understand that if I provide false information on the form it may lead to criminal charges. I understand that failure
to execute the form or failure to provide information or financial records constitutes a waiver of the right to the
appointment of a public defender. I am authorizing that the facts contained in this Affidavit may be verified by any
means required. I declare under penalty of perjury that everything I stated in this document is true and correct.
Minn. Stat. § 358.116.
Dated:
Applicant’s Signature:
County and State Where Signed
---------------------------------------------Applicant Do Not Fill Out Below This Line--------------------------------------------------------
Instructions for completing the questions on this form:
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Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
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