MC-210 FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PEOPLE OF THE STATE OF CALIFORNIA v. DEFENDANT: DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT (check all that apply) ELIGIBILITY FOR APPOINTMENT OF COUNSEL REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL CASE NUMBER: ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE 1. a. Defendant's name: d. Date of birth: b. Other names used: e. Telephone number: f. Driver's license number: c. Address: 2. Defendant's present employment: a. Occupation: b. Name of employer: c. Address: d. Gross pay per month: $ e. Take-home pay per month: $ f. Name of union: g. Name of credit union: week: $ day: $ week: $ day: $ 3. If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was employed. a. Name: b. c. 4. Address: Last date of employment: Defendant 5. a. b. is is not married. Spouse's name: d. Date of birth: Other names used: e. Telephone number: f. Driver's license number: c. Address: 6. Spouse's present employment a. Occupation: b. Name of employer: c. Address: d. Gross pay per month: $ e. Take-home pay per month: $ f. Name of union: g. week: $ Name of credit union: week: $ day: $ day: $ 7. If spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed. a. Name: b. c. Address: Last date of employment: 8. Dependents Name Address Relationship Aqe Page 1 of 2 Form Approved for Optional Use Judicial Council of California MC-210 [Rev. January 1, 2009] DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND RECORD ON APPEAL AT PUBLIC EXPENSE Pen. Code, § 987. 8 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com MC-210 CASE NUMBER: PEOPLE OF THE STATE OF CALIFORNIA v. DEFENDANT: 9. a. Defendant Unemployment and disability OTHER MONTHLY INCOME .............. $ a. Spouse Unemployment and disability .............. $ b. Social Security ..................................... $ b. Social Security ..................................... $ c. Welfare, TANF ................................... $ c. Welfare, TANF ................................... $ d. Veteran's benefits ................................. $ d. Veteran's benefits ................................. $ e. Worker's compensation ...................... $ e. Worker's compensation f. Child support payments ......................... $ f. Child support payments ......................... $ $ g. Spousal support payments ................... $ g. Spousal support payments ................... $ h. All other income not elsewhere listed ... $ h. All other income not elsewhere listed ... $ ...................... Total: $ Total: $ 10. EXPENSES Monthly expenses being paid by defendant alone or by defendant and spouse $ f. ............................ $ ..................................... $ g. Food ..................................................... $ Transportation payments ..................... $ h. Support payments ................................ $ Medical and dental payments .............. $ i. Insurance payments ............................. $ Loan payments .................................... $ j. Other payments (union, taxes, utilities) ... $ a. b. Car payments c. d. e. 11. Rent or house payments ....................... Clothing and laundry Total (a-j): $ Installment payments other than those listed in item 10. Name of Creditor MonthIy Payment Balance Owed a. $ $ $ c. $ $ d. $ $ e. $ $ Total: $ 12. $ b. Total: $ ASSETS What do you own? (State value): a. Cash b. House equity ................................................................................................. $ c. Cars, other vehicles and boat equity ............................................................. (List make, year, and license number of each) $ d. Checking, savings, and credit union accounts (List name and account number of each) $ e. Other real estate equity ................................................................................ $ f. Income tax refunds due ................................................................................. $ g. Life insurance policies (ordinary life, face value) h. ............................................................................................................... ................................................. $ .......................................... $ Other personal property (jewelry, furniture, furs, stocks and bonds, etc.) ...... $ Length of ownership Total: $ 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 a portion 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 or part 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 Defendant I 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. Date: (Signature of Defendant) MC-210 [Rev. January 1, 2009] DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND RECORD ON APPEAL AT PUBLIC EXPENSE Page 2 of 2