Defendant married.Defendant's present employment:If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was employed.Spouse's present employmentIf spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed.Dependents Name Address Relationship Age DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND RECORD ON APPEAL AT PUBLIC EXPENSEPen. Code, 247 987. 8 www.courts.ca.govForm Approved for Optional Use Judicial Council of California CR-105 [Rev. September 1, 2018]Page 1 of 27.1.a.b.c.d.e.f.8.6.2.3.a.b.c.d.e.f.g.b.c.CR-1054.5. DEFENDANT:PEOPLE OF THE STATE OF CALIFORNIA v. FOR COURT USE ONLY DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT (check all that apply)ELIGIBILITY FOR APPOINTMENT OF COUNSEL REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE Defendant's name:Other names used:Telephone number:Driver's license number:Address:Occupation:Name of credit union:Name of union:Gross pay per month: $ week: $ day: $ Address:Name of employer:Take-home pay per month: $week: $ day: $ Address:Name:Last date of employment:is is not a.b.c.d.e.f.Spouse's name:Other names used:Telephone number:Driver's license number:Address:a.b.c.d.e.f.g.Occupation:Name of credit union:Name of union:Gross pay per month: $ week: $day: $ Address:Name of employer:Take-home pay per month: $week: $ day: $ a.b.c.Address:Name:Last date of employment:Date of birth:Date of birth:a. SUPERIOR COURT OF CALIFORNIA, COUNTY OFSTREET ADDRESS:MAILING ADDRESS:CITY AND ZIP CODE:BRANCH NAME: CASE NUMBER: American LegalNet, Inc. OTHER MONTHLY INCOMEDefendant 9.Spouse EXPENSESMonthly expenses being paid by defendant alone or by defendant and spouseInstallment payments other than those listed in item 10.MonthIy Payment Balance Owed a. b.c.d.e.Total: $ASSETSWhat do you own? (State value):Cash House equity Cars, other vehicles and boat equity (List make, year, and license number of each)Checking, savings, and credit union accounts (List name and account number of each)Other real estate equityIncome tax refunds due Life insurance policies (ordinary life, face value) Other personal property (jewelry, furniture, furs, stocks and bonds, etc.) 13. ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO DEFENDANT: If an attorney is appointed to represent you,the court will, at the conclusion of the criminal proceedings, after a hearing, make a determination of your ability to pay all or aportion of the cost of the attorney. If the court determines that you are at that time able to pay, the court will order you to pay all orpart of such cost. Such an order will have the same force and effect as a judgment in a civil action and will be subject to execution.Declaration of DefendantI declare under penalty of perjury that the foregoing is true and correct, and that I understand the notice contained in item 13, under the laws of the state of California.SIGNATURE OF DEFENDANTName of Creditor CR-105e.d.a.c.b.f.h.g.e.d.a.c.b.h.g.f.Unemployment and disability Social Security Welfare, TANF Veteran's benefits Worker's compensation Child support payments Spousal support payments All other income not elsewhere listed Total: $ $ $ $ $ $ $ $ $e.d.a.c.b.h.g.f.Unemployment and disability Social Security Welfare, TANF Veteran's benefits Worker's compensation Child support payments Spousal support payments All other income not elsewhere listed CASE NUMBER: PEOPLE OF THE STATE OF CALIFORNIA v.DEFENDANT:Total: $ $ $ $ $ $ $ $ $11. 10. Rent or house payments Clothing and laundryFood Support payments Insurance payments Other payments (union, taxes, utilities)Total (a-j): j.i.f.h.g. $ $ $ $ $ $Car payments Transportation payments Medical and dental payments Loan paymentse.d.a.c.b. $ $ $ $ $ $ $ $ $ $Total: $ $ $ $ $ $12. Total: $ $ $ $ $ $ $ $ $ Length of ownership Date: DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND RECORD ON APPEAL AT PUBLIC EXPENSEPage 2 of 2 CR-105 [Rev. September 1, 2018] American LegalNet, Inc.