State of South Dakota ) in Circuit Court
UJS 224 (10/2011)
STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT
) SS JUDICIAL COURT
COUNTY OF )
STATE OF SOUTH DAKOTA )
) APPLICATION
VS )
) FOR
)
(print your name) ) COURT – APPOINTED COUNSEL
I have been charged with the crime(s) of which is
a (check one) FELONY MISDEMEANOR under South Dakota law. I hereby swear on oath and under penalty of law
that the following is true.
I (HAVE) (HAVE NOT) TRIED TO HIRE MY OWN LAWYER. Who:
.
(1) I am financially unable to hire a lawyer to represent me in my defense
(2) My address is ; my email address is
(3) My telephone number is: ; my date of birth is
(4) I am (check one) EMPLOYED UNEMPLOYED SELF EMPLOYED
(5) (If employed) my weekly take home pay is: $ .
(6) Retirement, disability, or insurance benefits: $ per .
(7) My total income before deductions for the previous year was $ .
(8) My total year-to-date income before deductions for the current year is $ .
(9) Including myself, I have the following number of dependants: .
(10) The following amounts accurately represent my assets and liabilities:
I. ASSETS(things I own or am buying)
a. CASH (on hand or in banks) ……………………………………………………………………………………….. $
b. ACCOUNTS and NOTES RECEIVABLE (IOU’s and other money payable to me)……………………………… $
c. INVESTMENTS (stocks, bonds, savings bonds, etc)………………………………………………………………. $
d. REAL ESTATE (house, land, tribal lease land, rental property, etc)……………………………………………….. $
e. AUTOMOBILE (S) make, model & year:
____________________________________________________________________________________________ $
f. HOUSEHOLD GOODS(furniture, appliances, TV, stereo, etc.)……………………………………………………. $
g. OTHER PERSONAL PROPERTY (tools, sports equipment, etc)…………………………………………………. $
h. ANY OTHER ASSETS(anything else I could sell or borrow money on)…………………………………………… $
TOTAL ASSETS $
II. LIABILITIES (money that I owe)
a. My regular monthly expenses are: (housing, utilities, food, etc.)………………………………………………….. $
b. LOANS: I owe this amount………………………………….. $
I owe this amount………………………………….. $
I owe this amount………………………………….. $
TOTAL LIABILITIES $
III. ANTICIPATED INCOME (money or property you are expecting)
a. Total monies or income from sale of house or land, alimony, gifts, inheritance, allotments,
Trust funds, lease money, etc……………………………………………………………………………………… $
(11) I understand that if I have a court-appointed lawyer, his fees are loaned and not given to me. I will be asked to repay the county,
If I am able, and a lien will be filed against my property to insure payment.
Dated this day of , 20 .
X_______________________________________, Defendant
Subscribed and sworn to before me this day of , 20 .
My commission expires: ___________________________________________________
(Magistrate, Circuit Judge, Notary)