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 I made be responsible for costs associated with Public Defense services provided by the State. 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.
REQUIRED FEE: You must pay a $35 fee when submitting this application.The Court may waive or reduce the fee if you cannot pay the entire fee.If the fee is not waived and you do not pay the fee, the amount will be added onto any costs you are ordered to reimburse at the conclusion of your case.
NOTICE:You may be required to submit verification of your gross income.Verification of gross income includes one of the following:
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
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