AMADOR SUPERIOR COURT 500 ARGONAUT LANE JACKSON, CA 95642 PEOPLE OF THE STATE OF CALIFORNIA VS __________________________________________ FOR COURT USE ONLY DEFENDANT'S FINANCIAL STATEMENT PENAL CODE §987(c) (CONFIDENTIAL) Personal Information 1. a. Full Name: b. Date of Birth: c. Social Security #: d. Driver's License #: State of issuance: Employment 2. What are your sources of income and occupation? CASE NUMBER: e. Home Address: City, Zip f. Home telephone no.: 3. a. Name, address and phone number of your business or employer: b. If not employed, list all sources of income (specify names and addresses): 4. How often are you paid (daily, weekly, biweekly, monthly?) _________________________________________ 5. What is your gross pay each pay period? $_________________________________ 6. What is your take-home pay each pay period? $______________________________ 7. 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. All 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. FINANCIAL STATEMENT PC 987(c)-(Rev. 03/2013)-CRIM-230 $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Property 11. List all automobiles, other vehicles (ATV, Mobile Home/Trailer, etc.), and boats owned in your name or jointly: Make and Year Value Legal Owner Balance a. b. c. $ $ $ $ $ $ 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 No If yes describe the assets and give the name and address of the person or entity holding each asset (specify): Debts 16. Loans (give details): 17. Taxes (give details): 18. Support arrearages (attach copies of orders and statement): 19. Credit cards (give creditor's name and address and account number): 20. Other debts (specify): Notice: The court may order you to answer questions about your finances and later order you to pay back the waived fees. If this happens and you do not pay, the court can make you pay the fees and also charge you collection fees. If there is a change in your financial circumstances during this case that increases your ability to pay fees and costs you must notify the trial court within five days (Use Defendant's Financial Statement form.) I declare under penalty of perjury under the laws of the State of California the information I have provided on this form and all attachments is true and correct. I understand in signing this form that I may be responsible for reimbursing the county for court appointed attorney fees. Date: __________________________________ __________________________________________ Print your name here _______________________________________________ Sign here FINANCIAL STATEMENT PC 987(c)-(Rev. 03/2013)-CRIM-230 American LegalNet, Inc. www.FormsWorkFlow.com