Page 1 of 4 AS 18.85 CR-206 ()(cs) FINANCIAL STATEMENT IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT State of Alaska ) In the Matter of ) ) vs. ) CASE NO. ) ) FINANCIAL STATEMENT Defendant or Minor. ) For Appointment of Counsel ) For Restitution Full Name Date of Birth Residence Address Mailing Address Email Address Soc. Sec. No. 1 Home Phone Work Phone Cell Phone Are you under the age of 18? No Yes. If yes, one of your parents must appear and provide financial information regarding the income of both parents. Have you filled out a financial statement to apply for a court-appointed attorney within the past 12 months? Yes No Was an attorney appointed for you? Yes No Are you receiving public assistance? No Yes. If yes, check those you receive: SSI Food Stamps Adult Public Assistance ATAP General Relief Medicaid Are you working now? Yes No If no, date last worked Present employer (If not now employed, state last employer and length of job.) address Other employers in past year Are you a seasonal worker? Yes No If yes, describe: Are you self-employed? Yes No If yes, describe: 1. (after taxes, but before other deductions) Do not include income of spouse. If under age 18, list income of defendant and parents. a.Current Monthly Income Wages $ Social Security $ Public Assistance $ Unemployment $ Self-Employment Income (attach proof 2 ) $ Other (specify) $ Total Monthly Income $ b.Permanent Fund Dividends received in last 12 months$ c.ANCSA or other corporate dividends received in last 12 months$ d.Value of gifts received in last 12 months$ e.Total Income during last 12 months$ 1 Social Security number is not mandatory. It may be used to identify your assets. 2 Examples include sales tax reports, bank statements, tax returns, cannery settlement statements. Crim. R. 32.1, 32.6 39, and 39.1 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 CR-206 ()(cs) FINANCIAL STATEMENT AS 18.85 f.Do you expect to receive other income in the next 6 months (for example,settlements, dividends, gifts, inheritances)? Yes No If yes, please specify 2.HOUSEHOLD MEMBERS (People who live with you) Name AgeRelationship 3.MONTHLY HOUSEHOLD EXPENSES ExpenseAmount Balance Owed Past Due Housing (rent or mortgage)$ $ $ Food$ $ $ Utilities: Electricity $ $ $ Gas $ $ $ Water and Sewer $ $ $ Garbage $ $ $ Telephone $ $ $ Transportation (gas/bus) $ $ $ Car or truck payment $ $ $ Insurance $ $ $ Child support and alimony $ $ $ List Loans & Credit Card Debts: $ $ $ $ $ $ $ $ $ $ $ $ Medical (not covered by insurance) $ $ $ Childcare: $ $ $ IRS Back Taxes Due $ $ $ TOTALS $ $ $ ADJUSTMENTS TO EXPENSES: a.Are you married? Yes No after taxes for the past 12 months (include gifts, settlements, inheritances, wages, dividends, etc.): $ Note: For purposes of deciding appointment of counsel, expenses will be divided between the spouses proporti b.Are any household expenses paid by someone other than you or your spouse(such as by a roommate, parent, grandparent or child)? No Yes. If yes, list: $ Name Relationship Amount $ Name Relationship Amount $ Name Relationship Amount Crim. R. 32.1, 32.6 39, and 39.1 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 CR-206 ()(cs) FINANCIAL STATEMENT AS 18.85 4.CASH AND ASSETS (things you own or are buying) Include all things you own byyourself and all things you own jointly with someone else. Value Amount Still Owed Cash $ Bank Acct./Checking $ Bank Acct./Savings $ $ Mutual Funds $ Retirement Plans $ Life Insurance (cash value) $ Land, Homes, Trailers $ $ Motor Vehicles (describe): $ $ $ $ $ $ $ $ TV, Stereo, VCR $ $ Computer Equipment $ $ Snow Machines, ATVs, Sport Boats, Airplanes, Motorcycles $ $ Jewelry, Precious Metals or Precious Stones $ $ Furs ......................................... $ $ Collections (Coins, Ivory, etc.) $ $ Tools ....................................... $ $ Guns ....................................... $ $ Sports Equipment (Kayaks, Skis, Scuba Gear, etc.) $ $ Fishing Gear, Nets, etc. ........... $ $ Quota Shares, etc. ........ $ $ Commercial Fishing Permits .... $ $ Commercial Fishing Boats. ...... $ $ Businesses: $ $ $ $ Other: $ $ $ $ TOTALS $ (-) $ = $ Do you need any of the above items to earn your living? Yes No If yes, list the item and describe why you need it: Crim. R. 32.1, 32.6 39, and 39.1 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 CR-206 ()(cs) FINANCIAL STATEMENT AS 18.85 5.CREDIT CARDS. List all your credit cards.Min. Monthly Name of Card (Visa, MC, AMEX) Credit Limit Balance Owed Payment $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 6.OTHER EXPENSES ExpenseMonthly Amount Cable TV$ Club Membership Fees$ Internet Fees$ Subscriptions (magazines, newspapers, etc.)$ Entertainment (dining out, sporting events, etc.)$ Alcohol and Tobacco$ TOTAL $ OATH WARNING: Making false statements under oath is a crime. I declare, under oath, that the above Financial Statement is true. Date Signature of Defendant or Parent Subscribed and sworn to or affirmed before me in , Alaska on . (date) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: (SEAL) Crim. R. 32.1, 32.6 39, and 39.1 American LegalNet, Inc. www.FormsWorkFlow.com