CR-115 NAME OF VICTIM ON WHOSE BEHALF RESTITUTION IS ORDERED: FOR COURT USE ONLY NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT: CASE NUMBER: DEFENDANT'S STATEMENT OF ASSETS It is a misdemeanor to make any willful misstatement of material fact in completing this form (Pen. Code, § 1202.4(f)(4).) (Attach additional sheets if the space provided below for any item is not sufficient.) PERSONAL INFORMATION 1. a. Name: f. Driver license number: b. AKA: State of issuance: g. Home address (incl. city/zip): c. Date of birth: d. Social security number: h. Home telephone no.: e. Marital status: i. Employer's telephone no.: EMPLOYMENT 2. What are your sources of income and occupation? (Provide job title and name of division or office in which you work.) 3. a. Name and address of your business or employer (include address of your payroll or human resources department, if different): b. If not employed, names and addresses of all sources of income (specify): 4. 5. 6. 7. How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify): What is your gross pay each pay period? $ What is your take-home pay each pay period? $ If your spouse earns any income, give the name of your spouse, the name and address of the business or employer, job title, and division or office (specify): 8. Other sources of income (specify): CASH, BANK DEPOSITS 9. How much money do you have in cash? $ 10. How much other money do you have in banks, savings and loans, credit unions, and other financial institutions either in your own name or jointly (list): Name and address of financial institution Account number Individual or joint? Balance a. b. c. PROPERTY 11. List all automobiles, other vehicles, and boats owned in your name or jointly. Make and year Value $ $ $ Legal owner if different from registered owner Amount a. b. c. Adopted for Mandatory Use Judicial Council of California CR-115 [Rev. July 1, 2013] $ $ $ (Continued on reverse) $ owed $ $ Penal Code, § 1202.4(f) American LegalNet, Inc. www.FormsWorkFlow.com DEFENDANT'S STATEMENT OF ASSETS PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT: CASE NUMBER: 12. List all real estate owned in your name or jointly: Address of real estate Fair market value Amount owed a. b. $ $ $ $ OTHER PERSONAL PROPERTY (Do not list household furniture and furnishings, appliances, or clothing.) 13. List anything of value not listed above owned in your name or jointly (continue on attached sheet if necessary): Description Value Address where property is located a. $ b. $ c. $ ASSETS 14. List all other assets, including stocks, bonds, mutual funds, and other securities (specify): 15. Is anyone holding assets for you? Yes. person or entity holding each asset (specify): No. If yes, describe the assets and give the name and address of the 16. Except for attorney fees in this matter and ordinary and routine household expenses, have you disposed of or transferred any assets since your arrest on this matter? Yes. No. If yes, give the name and address of each person or entity who received any asset and describe each asset (specify): DEBTS 17. Loans (give details): 18. Taxes (give details): 19. Support arrearages (attach copies of orders and statements): 20. Credit cards (give creditor's name and address and the account number): 21. Other debts (specify): Date: (TYPE OR PRINT NAME) (SIGNATURE) I, (name): in the (specify language): the form and he/she completed the form. Date: , a certified interpreter, having been duly sworn, truly translated this form to the defendant language. The defendant indicated that he/she understood the contents of (TYPE OR PRINT NAME) CR-115 [Rev. July 1, 2013] (SIGNATURE) DEFENDANT'S STATEMENT OF ASSETS Page two