SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF NEVADA FINANCIAL DECLARATION Date: Employer: Address: Phone number: Birthdate: I, , am the defendant in the above entitled action. I am not represented b y counsel in this proceeding. My assets, monthly income, property, monthly expenses and debts are reported below: MONTHLY INCOME AMOUNT ASSETS AMOUNT Monthly take home pay Cash Spouses' monthly take hom e pay Checking / savings / credit union Other money received each month Stocks and Bonds TOTAL MONTHLY INCOME TOTAL VALUE OF ASSETS PROPERTY TYPE/ADDRESS EQUITY/VALUE BALANCE OWED Home Automobile Other land/building Motorcycles Other Vehicle(s) Jewelry Other MONTHLY EXPENSES AMOUNT MONTHLY EXPENSES AMOUNT Rent or mortgage School, child care Food and Household supplies Child, spousal support Utilities and telephone Transportation/Auto expenses Medical and dental payments Install payment (Itemize below) TOTAL TOTAL INSTALLMENT PAYMENTS/CREDITOR NAME MONTHLY PAYMENT BALANCE OWED TOTAL PAYMENTS The following person other than myself depend, in whole or in part, on me or my spouse for support NAME ADDRESS RELATIONSHIP AGE I hereby authorize the Public Defender to disclose any of the information on this application and declaration to such qualifi ed authorities as may be deemed necessary in reaching a proper decision on my rights to be defended by the Public Defender I understand the Court, after a hearing pursuant to PC247987.8, will make a determination of my present ability to pay all or part of the costs of the attorney services provided; that the Court may order me to pay such costs, that such order shall have the same force and effect as a judgement in a civil action and shall be subject to enforcement against my property in the same manner as any other money judgment, and the Court may look at this financial affidavit when deciding whether or not I shall pay I realize that if the services of the Public Defender are obtained through the use of false, untrue or incorrect statements c oncerning my fina ncial condition, criminal prosecution for theft or perjury may result. I DECLARE UNDER PENALTY OF PERJURY that I have read this affidavit or this affidavit has been read to me and that the statements contained therein are true and correct Executed this day of , , in the County of Nevada. signature American LegalNet, Inc. www.FormsWorkFlow.com