Application for Indigent Defense Services Criminal/Adult in Juvenile Cases

Questions about this application? Contact the Clerk of Court where your criminal case is filed.

Are you a parent/respondent in a juvenile case? Yes No

County of Case

Client

First Name

Middle Initial

Last Name

Alias

Address

City

State

Zip

Best Phone Number

Email Address

Are you currently in jail?

Yes No

Case Number(s) Case Lookup Separate multiple case numbers with a comma.

Are you receiving any of the following government benefits? (select all that apply)

TANF: Yes No

Medical Assistance for the Elderly: Yes No

Supplemental Security Income: Yes No

*Note: If any of the benefits above are selected, attach supporting documentation and skip to the ACKNOWLEDGEMENT section.

None of the Above Benefits apply - Note: If this box is checked ALL fields below (questions 1-6) MUST be completed. Yes No

INCOME AND ASSETS

1. Employment

Do you have a job? Yes No

Hourly Wage

Hours per Week

x 4.3

Monthly Earnings (before taxes)

Will You Still Have Job After Arrest?

Yes No

2. Other Income

Within the past 12 months, have you received income from any other source, such as from self-employment, businesses, rent payments, tribal payments, mineral interests/royalties, interest, dividends, retirement benefits, social security or disability payments?

Yes No

Source

Amount

Do a spouse provide financial support to you?

Yes No

Spouse Financial Support Amount

Spouse Hourly Wage

Hours per Week

x 4.3

Monthly Earnings (before taxes)

3. Property and Assets

Own Property or Have Additional Assets

Yes - see below No

List all assets, approximate worth, and any loan against it:

Asset

Asset Worth

Asset Owed

Asset 2

Asset Worth 2

Asset Owed 2

4. Cash and Bank Accounts

Do you have any cash or money in savings or checking accounts? Yes No

Cash/Account Type

Amount

5. Household Size

Number of People in your Home you are Financially Responsible For (people listed on your tax return)

6. Describe Extraordinary Financial Considerations

Explain

ACKNOWLEDGMENT

I have answered all questions honestly to the best of my knowledge and I am requesting a lawyer be appointed to represent me. I understand that the information supplied on this form is confidential. I also understand that if I have supplied false information in the application, it may lead to criminal prosecution. If counsel is appointed, I understand I have a continuing responsibility to inform the court of any changes in my financial condition, employment status, or household size. I understand that by signing this application I give authorization for investigation into my income, assets and benefits, and this form will serve as a release of information to any source which might have such information including, but not limited to, claim information from Workforce Safety and Insurance.

Signature

Date

Browse Files To attach multiple files, select files one by one while pressing control key or if you want to select all files in a directory, press Ctrl+A keys.

INSTRUCTIONS FOR THE APPLICATION FOR INDIGENT DEFENSE SERVICES

NOTICE:You may be required to submit verification of your gross income.Verification of gross income includes one of the following:

most recent pay stub reflecting current wages, or
most recent W-2, or
most recent tax return, or
written statement from employer.

All questions must be answered, or the application will be denied, answers of zeros, slashes, or n / a will not be accepted. Please reference the guidelines located on the CLCI Website(www.indigents.nd.gov).

INCOME AND ASSETS

Employment If you have a job, list the amount you make before taxes.
Other Income List any income received from sources referenced in guidelines(3a1).Sources may include: social security payments, strike benefits from union funds, veteran's benefits, training stipends, alimony, child support, military family allotments, foster care payments, public or private employee pensions, regular insurance or annuity payments, income from dividends, interests, rents, royalties, trusts, unemployment compensation, state or county general assistance or home relief, money received from sale of real or personal property, non-cash benefits (food stamps), payments from rental of Indian Trust Land and Tribal per capita payments.
Property and Asset Assets may include: annuities, assets owned with another person, business accounts, certificates of deposit, farm equipment, livestock, stored grain, any home or residence, tools or other equipment, inheritance, mineral rights, retirement funds, savings bonds, or mutual funds.Please make sure to include any amount owed against property and assets.
Cash and Bank Accounts Please list all cash on hand, amounts in checking, savings and debit card accounts, credit union accounts or cash app accounts.
Household Size Applicant, applicants spouse and children who are the legal responsibility of the applicant.
Describe Extraordinary Financial Considerations Please share if income is seasonal, there are outstanding medical bills, or any other details that would impact income or the ability to pay for a private attorney.

Applications need to be submitted to the clerk of court in the county in which an individual is charged.For court locations please visit: https://www.ndcourts.gov/court-locations