PERSONAL DATA Full Name:_________________________________Age:_____ DOB:__________Booking No:_____________ Address:__________________________________________ Telephone: ( Marital Status: Single Married Divorced Separated Widowed Driver's License No:_________________________ Social Security No:_______________________________ Name of Wife/Husband:___________________________ Children: Number_______ Ages________________ YOUR EMPLOYMENT Occupation Employer Employer Address Business Telephone How long employed? Gross Salary: Take Home Pay All Other Income: $ $ $ $ (Week/Month) (Week/Month) $ $ $ $ (Week/Month) (Week/Month) WIFE/HUSBAND EMPLOYMENT ) _________________________ WHAT DO YOU OWN? House Vehicle #1 Vehicle #2 BANK ACCOUNTS: Savings Balance Checking Balance OTHER: PRESENT VALUE $ $ $ $ $ $ LIST YOUR MONTHLY EXPENSES 1. Rent or House Payment $ 2. Car Payments $ 3. Medical Payments $ 4. Loan Payments $ 5. Clothing and Laundry $ 6. Food $ 7. Other $ 8. Other $ WAIVER OF HEARING REGARDING PUBLIC DEFENDER OR COURT APPOINTED COUNSEL FEES AND COURT ORDER Penal Code Section 987.8: In any case in which a defendant is provided an attorney, either a Public Defender or Court-appointed counsel, upon conclusion of the criminal proceedings, or withdrawal of the Public Defender, the Court may, after notice and a hearing, make a determination of the present ability of the defendant to pay all or a portion of the cost of that legal representation. The Court may hold an additional hearing within six (6) months of the conclusion of the criminal proceedings. The Court may order a defendant to appear before a county officer to inquire into the defendant's ability to reimburse the county for legal assistance. MUST INITIAL ONLY EITHER OPTION NUMBER 1 OR 2 and then sign below 1. INTIAL: ---- I AGREE TO WAIVE my right to a Court hearing on the issue of attorney fees. I further understand and agree that, although the Court does not have to accept this waiver, the Court MAY enter a judgment against me for a flat fee of $150 (for a misdemeanor)/ $300 (for a felony), as the total amount of my contribution toward my legal representation by the Public Defender. 2. INITIAL: ---- I DO NOT AGREE TO WAIVE the right to have a Court hearing on the issue of attorney fees AND I understand that the Court will assess attorney fees at $75.00 for each hour the Public Defender worked on my case, subject to my ability to pay AND this amount may likely be in excess of the flat fee of $150 (misdemeanor) or $300 (felony.) WAIVER and CONSENT TO ORDER I have read the information contained in the Financial Statement and I declare under penalty of perjury that the foregoing is true and correct. I hereby authorize the Amador Superior Court and its duly authorized representatives to contact any employer, bank, savings and loan, credit union, creditor, insurance company, attorney at law, or government agency regarding my financial condition; and I further authorize such institution, individual, partnership, corporation or agency so contacted to release any and all information requested regarding my assets, liabilities, policies, litigations, financial transactions and accounts. Executed at _______________________, California on _____________________________ ____________________________________ SIGNATURE OF DEFENDANT PUBLIC DEFENDER FEE WAIVER REQUEST FORM (04/26/16) - CRIM 242 American LegalNet, Inc. www.FormsWorkFlow.com