State of Alabama Unified Judicial System Form C-52(f) (front) Case Number Rev. 11/92 RELEASE QUESTIONNAIRE IN THE_______________________________________COURT OF __________________________________________, ALABAMA (Circuit, District or Municipal) (Name of County or Municipality) STATE OF ALABAMA MUNICIPALITY OF_____________________________ v.________________________________________ Defendant FOR THE PURPOSE OF DETERMINING CONDITIONS OF PRE-TRIAL RELEASE IN THIS CASE, THE COURT MAY TAKE INTO ACCOUNT THE FOLLOWING: 1. 2. Where do you presently reside? ____________________________________________________________, How long have you lived at the address? ______________________________, If you have lived there less than one (1) year, where was you previous residence? _________________________________________________________________________, How long did you reside at your previous residence? ______________________, (a) Are you presently employed ________, If so, by whom? ____________________________________, What is the nature of your job?________________________________________________________, If you have been employed less than one (1) year, where were you previously employed? ____________________, ________________________________________ How long did you work there? ______________________, What was the reason for your leaving? ______________________________________________________________, (b) What is your social security number? ______________________________________, (c) If you have not completed an Affidavit of Substantial Hardship, what is your approximate present net worth (value of all assets owned by you less $ ________________ $ ________________ Equals a Net Worth of 3. Assets of Minus Liabilities of all liabilities and debts owed by you) ? $ ________________ (a) Are you married? ______________, Do you and your spouse live together ? ____________________, How long have you been married? ___________, Have you been married before? _____________, If so, how was the marriage ended? By ___________________(divorce or death). (b) Do you have children? _________, If so, how many and what are their ages? _______________________, Do they reside with you? ________, If not, list the names and addresses of living children not residing with you. (If there are more names, please continue on an attached separate sheet of paper with the following information.) (c) ______________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) ______________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) Does any other member of your family reside in the same household? ___________________, Relationship: __________________________________________________________________________________________________ (d) The names and address(es) of your nearest living relatives not resident with you: (If there are more names, please continue on an attached separate sheet of paper with the following information.) ______________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) ______________________________________ (Name) ______________________________________________________________ (Address) (Telephone Number) 4. Who in the community where you reside can vouch for your character, reputation, and reliability? ____________________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) ____________________________________________ ______________________________________________________________ (Address) (Telephone Number) (Name) ____________________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) ____________________________________________ ______________________________________________________________ (Name) (Address) (Telephone Number) 5. Do you have any health problem? ______________________, If so, specify what problems. ________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com Form C-52(f) (back) 6. RELEASE QUESTIONNAIRE Rev. 11/92 (a) Have you ever been arrested before? __________________, If so, indicate date, county, state, charge and disposition: DATE COUNTY STATE CHARGE DISPOSITION Are any of these cases pending? _____________, If so, list the charges and court(s) where pending: CHARGE (b) COURT Have you ever been released form a prior arrest on bail or on your personal recognizance? ________________, If so, list when and where. ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ (c) Have you ever been arrested for not appearing in court or ever had a bond or release revoked? _____________, If so, list when and where ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ (d) Do you presently owe any unpaid court costs, fines, assessments or restitution? ______________, If so, list amount(s) owed and the name of the court(s): AMOUNT $ ___________________ COURT $ ___________________ $ ___________________ $ ___________________ I HAVE BEEN ADVISED THAT CORRECT AND TRUTHFUL ANSWERS TO THE FOREGOING QUESTIONS ARE NECESSARY IN ORDER FOR THE COURT TO MAKE A DETERMINATION OF WHETHER TO GRANT MY RELEASE. I HAVE BEEN NOTIFIED THAT FALSE STATEMENTS ARE PUNISHABLE AS PERJURY. __________________________________ Date _______________________________________________________________ Defendant _______________________________________________________________ Social Security Number _______________________________________________________________ Address _______________________________________________________________ City State Zip Code _________________________________________________ Telephone Number American LegalNet, Inc. www.USCourtForms.com