FOR COURT USE ONLY Attorney or party without attorney (Name, State Bar number, and address) TELEPHONE NUMBER: Email Address: ATTORNEY FOR (Name): FAX NUMBER: SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE Riverside: 4050 Main Street, Riverside, CA 92502 Hemet: 880 N. State Street, Hemet, CA 92543 Palm Springs: 3255 E. Tahquitz Canyon Way, Palm Springs, CA 92262 Case Number: Case Name: FINANCIAL STATEMENT AND NOTICE (PROBATE) (Check all that apply) ELIGIBLITY FOR APPOINTMENT OF COUNSEL REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL 1. d. Date of birth: b. Other names used: e. Telephone number: c. Address: 2. a. Party’s Name: f. Driver’s license number: Party’s present employment: a. Occupation: b. Name of Employer: c. Address: d. Gross pay per month: $ week:$ day:$ e. Take-home pay per month: $ week:$ day:$ f. Name of union: g. Name of credit union: 3. If party is not now working, state the name and address of party’s last employer and the last date party was employed. a. Name: b. Address: c. Last date of employment: 4. 5. Party is not married or in a registered domestic partnership. a. Spouse’s or Registered Domestic Partner’s name: d. Date of birth: b. Other names used: e. Telephone number: c. Address: f. Driver’s license number: FINANCIAL STATEMENT AND NOTICE (PROBATE) Form #RI-P30 Revised 4/5/10 Page 1 of 3 RI-P30 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: 6. Case Number: Spouse’s or Registered Domestic Partner’s present employment: a. Occupation: b. Name of Employer: c. Address: d. Gross pay per month: $ week:$ day:$ e. Take-home pay per month: $ week:$ day:$ f. Name of union: g. Name of credit union: 7. If spouse or registered domestic partner is not now working, state the name and address of spouse’s or registered domestic partner’s last employer and the last date spouse or registered domestic partner was employed. a. Name: b. Address: c. Last date of employment: 8. Dependents Name Address Relationship Age OTHER MONTHLY INCOME 9. Submitting Party Spouse or Registered Domestic Partner a. Unemployment and disability…... $ a. Unemployment and disability……………….... $ b. Social Security…………………… $ b. Social Security…………………………………. $ c. Welfare, TANF…………………… $ c. Welfare, TANF…………………………………. $ d. Veteran’s benefits……………….. $ d. Veteran’s benefits……………………………… $ e. Worker’s compensation…………. $ e. Worker’s compensation……………………….. $ f. Child support payments………….. $ f. Child support payments……………………….. $ g. Spousal support payments……… $ g. Spousal support payments………………........ $ h. All other income not listed………. $ h. All other income not listed…………………….. $ Total $ Total $ FINANCIAL STATEMENT AND NOTICE (PROBATE) Form #RI-P30 Revised 4/5/10 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: 10. Case Number: EXPENSES Monthly expenses being paid by the submitting party alone or by submitting party and spouse or registered domestic partner a. Rent or house payments………………. $ f. Clothing and laundry……………………... $ b. Car payments…………………………... $ g. Food………………………………………. $ c. Transportation payments……………… $ h. Support payments……………………….. $ d. Medical and dental payments………… $ i. Insurance payments……………………… $ e. Loan payments…………………………. $ j. Other payments (union, taxes, utilities)… $ Total (a-j): $ Name of Creditor Monthly Payment Balance Owed 11. a. $ $ b. $ $ c. $ $ d. $ $ Total: $ Total: $ 12. ASSETS What do you own? (State value): …………………………………………………………………………………………………….. a. Cash b. House equity …………………………………………………………………………………………..... c. Cars, other vehicles and boat equity……………………………………………………………………... (List make, year, and license number of each) d. Checking, savings, and credit union accounts …………………..………………………………….... (List name and account number of each) $ e. f. g. h. 13. $ $ $ $ $ $ $ Other real estate equity ………………………………………………………………………………... Income tax refunds due ……………………………………………………………………………….... Life insurance policies (ordinary life, face value) …………………Length of ownership Other personal property (jewelry, furniture, furs, stocks and bonds, etc.) ………………………....... ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO PARTY: If an attorney is appointed to represent you, the court will, at the conclusion of the proceedings, after a hearing, make a determination of your ability to pay all or a portion of the cost of the attorney. If the court determines that you are at that time able to pay, the court will order you 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. Declaration of Submitting Party I declare under penalty that the foregoing is true and correct, and that I understand the notice contained in item 13, under the laws of the state of California. Date: Signature FINANCIAL STATEMENT AND NOTICE (PROBATE) Form #RI-P30 Revised 4/5/10 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com