COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. INSTRUCTIONS: DEFENDANT'S STATEMENT OF ASSETS : Index No. A. Name of Victim The name of the victim who will receive restitution goes here. CR-117 : Plaintiff(s) : : : : Defendant(s) : ............. Calendar No. B. Superior Court of California Ask the clerk of your court or defendant's attorney for this information. JUDICIAL SUBPOENA C. Name of Defendant D. Case Number -against- Write defendant's name in the space provided. Fill in the criminal case number assigned in the space provided. E. Personal Information a.. .Defendant's.name.. . . . . . . . . . . . . . . . . . . . . . . . . . ........ .... b. If defendant has previously used another name, provide that name in the space provided. c. Defendant's date of birth. THE PEOPLE OF THE STATE OF NEW YORK d. Defendant's social security number. e. Defendant's marital status. TO f. Defendant's driver license number and the state of issuance. g. Defendant's home address. h. Defendant's home telephone number. GREETINGS: i. Defendant's employer's telephone number. F. Income and Occupation List defendant's sources of income and occupation. the Honorable Include defendant's job title and the name of the County of division or office where defendant works located at or worked. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court in room , G. Address of Employeron the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to addressand give evidence as a witness in this action on the part of the testify of defendant's a. Write the name and business or employer. b. If defendant is not employed, write the names and addresses of all sources of Your failure to comply with income. this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a H. Pay Period result of your failure to comply. Specify how often defendant is paid, that is, daily, weekly, monthly. I. Gross Pay Witness, Honorable Specify defendant's gross pay each pay period. Court in J. Take-Home Pay K. Spouse's Income , one of the Justices of the , 20 County, day of Specify defendant's take-home, that is, after-taxes pay for each pay period. If defendant is married and defendant's spouse is employed, specify the name and address of his or her employer, job title, and (Attorney must sign above and type name below) division or office. L. Other Sources of Income If defendant has additional sources of income that have not been listed, write them here. M. Cash Write the amount of money defendant has in cash. Attorney(s) for N. Accounts Complete the required information regarding any money held in defendant's name in accounts in banks and any other financial institutions. Office and P.O. Address Complete the required information regarding any automobiles and boats defendant owns or jointly owns. O. Automobiles Form Approved for Optional Use Judicial Council of California CR-117 [New January 1, 2004] INSTRUCTIONS: DEFENDANT'S STATEMENT OF ASSETS Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 1 of 2 www.courtinfo.ca.gov American LegalNet, Inc. www.USCourtForms.com P. Real Estate List all real estate owned in defendant's name or jointly Q. Other Personal Property List any valuable property that has not already been mentioned that defendant holds in his or her name or jointly. R. Assets List all other assets, including stocks, bonds, and mutual funds. S. Assets Held for You If anyone is holding any assets for defendant, check the "yes" box and describe the assets along with the name and address of each person or entity holding the assets. T. Transfer of Assets List any disposal or transfer of assets that defendant has made since his or her arrest on this matter. U. Loans If defendant has any outstanding loans, list them here. Give the details of the loan including why the loan was taken and to what institution defendant owes money. V. Taxes If defendant owes any past taxes, give the details here. W. Support Arrearages If defendant owes child or spousal support, attach copies of the orders and statements to this form. X. Credit Cards If defendant owes money on any credit cards, list the name of each creditor and the account number. Y. Other Debts If defendant has any additional debts that have not yet been listed, write them down in the space provided. Z. Date and Signature Indicate the date and defendant's name and have defendant sign in the spaces provided. AA. Interpreter If an interpreter was used to complete the document, he or she must print his or her name, include his or her signature, and indicate the date. CR-117 [New January 1, 2004] INSTRUCTIONS: DEFENDANT'S STATEMENT OF ASSETS Page 2 of 2