SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BANNING 311 E. Ramsey St., Banning, CA 92220 BLYTHE 265 N. Broadway, Blythe, CA 92225 INDIO 46-200 Oasis St., Indio, CA 92201 MURRIETA 30755-D Auld Rd., Ste. 1226, Murrieta, CA 92563 RIVERSIDE 4100 Main St., Riverside, CA 92501 RI-OTS17 PEOPLE OF THE STATE OF CALIFORNIA FOR COURT USE ONLY vs. DEFENDANT: CASE NUMBER: ELIGIBILITY FOR APPOINTMENT OF COUNSEL REIMBURSEMENT FOR COST OF COURT APPOINTED COUNSEL Defendant's Address: Domicilio del Acusado: Social Security No. Home Phone Number: Date of Birth: Name of Employer: Nombre del Empleador: Phone Number: Hours Worked: Address of Employer: Domicilio del Empleador: (STREET/CALLE ) (CITY/CIUDAD ) (ZIP/CODIGO POSTAL ) Número de Seguro Social: Fecha de Nacimiento: Rate of Pay: $ (STREET/CALLE) (CITY/CIUDAD) (ZIP/CODIGO POSTAL) I understand that if an attorney is appointed to represent me, the court will, at the conclusion of criminal proceedings, make a determination of my ability to pay all or a portion of the cost of the attorney. If the court determines that I am able to pay, the court will order me 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. Entiendo que si me asigna un abogado para que me represente, al concluir las actuaciones penales, el juez determinara mi capacidad para pagar la totalidad o parte del costo por los servicios de abogado. Si el juez determina que estoy en condiciones de pagar, se me ordenará que page la totalidad o parte de ese costo. Esta ordén tendra la mísma validez y efecto de una sentencía en una acción civil y estará sujeta a ejecución. (INTERPRETER) (DEFENDANT/ACUSADO) DECLARATION OF COUNSEL I, defendant and that I spent Dated: , declare that I am appointed counsel for the above-named hours in the defense of the cause before the court. (ATTORNEY FOR DEFENDANT) Page 1 of 2 Approved for Optional Use Riverside Superior Court RI-OTS17 [Rev. 07/01/03] [Rev. Format 06/07/13] ELIGIBILITY FOR APPOINTMENT OF COUNSEL riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com DEFENDANT: CASE NUMBER: ORDER Having heard all evidence offered on behalf of the defendant, the court finds: that the defendant does not have the present ability to reimburse the County of Riverside for cost of appointed counsel. that the defendant does have the present ability to reimburse the County of Riverside for the cost of appointed counsel. Therefore, it is ordered that the defendant pay the amount of $ through Enhanced Collections.. no later than Dated: (JUDGE) Page 2 of 2 Approved for Optional Use Riverside Superior Court RI-OTS17 [Rev. 07/01/03] [Rev. Format 06/07/13] ELIGIBILITY FOR APPOINTMENT OF COUNSEL riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com