Exempt From VRA Certif. Page 1 of 2 CR-445 (5/17) (cs) SENTENCING AFFIDAVIT Administrative Bulletin No. 43 IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) Plaintiff, ) ) vs. ) ) ) ) CASE NO. CR Defendant. ) ) SENTENCING AFFIDAVIT INSTRUCTIONS Instructions to Defendant: Because you have been ordered to pay a fine as part of your sentence, you are required to provide the court with the information listed below. If you fail to pay your fine as ordered, a bench warrant may be issued for your arrest or your fine may be , or contact your local court clerk. AFFIDAVIT Please Print 1. True and full name (including middle name): 3. Date of Birth: 4. Social Security No.: [It is not mandatory that you give your social security number. Your social security number may be used to identify assets which may be seized to collect your fine.] 5. Residence address: 6. Mailing address: 7. Phone Numbers. Home: Work: Page 2 of 2 CR-445 (5/17) (cs) SENTENCING AFFIDAVIT Administrative Bulletin No. 43 8. Employment information. Check all boxes which apply to you and fill in the blanks. Current employer's name: Employer's address: Self-employed. Type of business: Address of business: Employed on seasonal basis. Seasonal employer's name: dress: Currently unemployed. Last employer's name: Employer's address: 9. I have accounts at the following banks, investment firms and other financial institutions: 10. I own the following real property: Description of Property: Location of Property: (For example: house, land, condominium, etc.) (Street & house number, town & state) 11. I own the following motor vehicles (include type, year, model, and license numbers, if known): Date Signature of Defendant Subscribed and sworn to or affirmed before me on ,20 , at , Alaska. Judge/Clerk/Notary Public (SEAL) My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com