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Application And Order For Deferral Of Court Investigation Assessment Form. This is a California form and can be use in Contra Costa Local County.
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Tags: Application And Order For Deferral Of Court Investigation Assessment, CV-641, California Local County, Contra Costa
THIS FORM MUST BE KEPT CONFIDENTIAL
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):
FOR COURT USE ONLY
TELEPHONE AND FAX NOS:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: 725 Court Street
MAILING ADDRESS: P.O. Box 911
CITY AND ZIP: Martinez, CA 94553
Guardianship
Conservatorship of (Name):
Proposed
Minor
Conservatee
CASE NUMBER:
APPLICATION AND ORDER FOR DEFERRAL
OF COURT INVESTIGATION ASSESSMENT
1. PETITIONER (Name):
requests a court order deferring payment of assessment required by Probate Code 1513.1 or 1851.5. My address and date of birth are (specify):
Address:
2.
Birthdate:
Check applicable box:
The Ward
The Proposed Ward
The Conservatee
The Proposed Conservatee
is receiving financial assistance under one or more of the following programs:
a.
SSI/SSP: The Supplemental Security income and State Supplemental Payments Programs
b.
AFDC: The Aid to Families with Dependent Children Program.
c.
Food Stamps: The Food Stamps Program
d.
County Relief, General Relief (G.R.) or General Assistance (G.A.)
If you completed item 2, sign your name at item 7 and DO NOT fill out the rest of this form).
3.
Payment of the assessment would create a personal hardship for petitioner. If you checked this box you must complete
Item 5 and DO NOT complete Item 4.
4.
For Conservatorship cases only. Payment of the assessment would create a hardship for the estate. If you checked
this box you must complete Item 6.
5.
a.
b.
c.
d.
My pay changes considerably from month to month. (If you check this box, each of the amounts reported in Item 5 should
Be your average for the past 12 months).
$
Gross monthly pay
Total payroll deduction amount
$
Monthly take-home pay (a. minus b.)
Other income I get each month (Specify source and amount)
1.
$
e.
f.
2.
$
Total other income (d1. plus d2.)
Total monthly income (c. plus d.)
The number of people in my family, including me, supported by this money is:
9.
Total monthly expenses
h.
$
I own the following:
Cash
$
Checking, savings and credit union accounts (list banks)
1.
$
$
$
$
2.
$
3.
$
Cars, other vehicles, boats (list make, model and value)
1.
$
2.
$
Real estate equity
$
Other personal property- jewelry, furniture, furs, stocks, bonds, etc.
(list separately)
$
Total assets (total of all items listed under h.)
$
CV-641/10-25-00
(Form Continued on Reverse)
CONFIDENTIAL
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i. Other facts which support this application are (Describe unusual medical needs, expenses for recent family emergencies, or other unusual expenses
to help the judge understand your budget). If more space is needed, attach page labeled "Attachment 5".
6. Estimated value of the property of the estate:
a. Personal Property
$
b. Annual gross income from
1.
Real property
$
2.
7.
Personal property
$
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Dated:
(Signature)
(Type or print name)
ORDER
It is ordered that the above Application for Deferral of Court Investigation Assessment is:
granted subject to reconsideration
after the investigation.
Denied
Dated:
Judge of the Superior Court
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