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)