Application For A Public Defender - State Of Minnesota Page 6
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6A. ADDRESS: where you are staying, if you are at a temporary address (for instance, if you are prohibited from
returning to your residence), and also the complete address of where you get your mail.
B. PHONE NUMBERS, E-MAIL: Your attorney needs to be able to contact you at all times, especially by phone. You
should include any number that you can be contacted at, including message phones. If you are not the owner of a
number, please include the name of the person who is.
1. MEANS TESTED PUBLIC ASSISTANCE: List only for you, and any of your legal dependents who live with you; specify
type of assistance received, who receives it, and the amount. A means tested benefit (including cash, medical,
housing, and food assistance and social services) is one in which the eligibility for benefits, or the amount of such
benefits, or both are determined on the basis of income, resources, or financial need.
7. GROSS INCOME: Income before taxes and other deductions are taken out.
1 and 15. DEPENDENTS: Someone that you are otherwise legally responsible for, generally a biological, step or legally
adopted child age 18 or younger, but may also include a disabled family member living with you.
14. OTHER INCOME OR MEANS OF SUPPORT: Such as from a parent, court settlement or a business you own. If so,
indicate that here and provide a description of the income.
17. OTHER ASSETS: Include anything that can be sold, pawned or pledged for cash, such as all vehicles, boats,
snowmobiles, motorcycles, ATVs, bonds, real estate or real property not previously listed, etc. Please provide specific
information here, including a description of the asset, make/model/value and the amount of any loan on the asset.
19. HOUSING COSTS YOU PAY: If you own your home, please be sure to include what your home is worth and the
amount remaining on your loan. If you share rent, list only the portion you pay.
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Created by the State Public Defender, August 2012 (Minn. Stat. § 611.17(b)).
Rev 7/15
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