COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUPERIOR COURT OF CALIFORNIA - COUNTY OF SAN MATEO : Index No. : DECLARATION UNDER PENALTY OF PERJURY TO OBTAIN SERVICES Calendar No. OF COURT-APPOINTED COUNSEL : JUDICIAL SUBPOENA CASE NUMBER: __________________________________ Plaintiff(s) Answer every question Please print -against: NAME: ______________________________________ DOB: _________________________________ LAST FIRST MIDDLE DAY YEAR :MO. ADDRESS: ____________________________PLACE OF BIRTH: :_____________________________ NO STREET STATE OR NATION Defendant(s) : . .______________________________________. SOCIAL . . . . . . . . . NO: ________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECURITY CITY STATE TELEPHONE NUMBER:( ) ____________________________ EMPLOYMENT ____________________________________________________________________________________ ) ___________________________ ( THE PEOPLE OF THE STATE OF NEW YORK RESIDENCE TO Are you self-employed or do you NOW have a job ( ) yes ( ) no. Name and address of Employer: ____________________________________________________ ______________________________________________________________________________ GREETINGS: 2. Do you expect to start working soon? ( ) yes ( ) no 3. If you are unemployed, how have you supported yourself while not working__________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ______________________________________________________________________________ , the Honorable at the Court located any County ofDo you receive any money from at other source (welfare, pension, unemployment, disability, 4. in room alimony, ,spousal support etc.)? on the day of , at noon, and at any recessed (, 20 ) yes ( ) o'clock in the no or5. adjourned date, towife (husband) have a job? as a(witness in this action on the part of the testify and give evidence Does your ) yes ( ) no 6. Does your wife (husband) receive any money from any other source? ( ) yes ( ) no 7. Do you own, or are you buying your home? ( ) yes ( ) no 8. Do you have a comply account? ( ) yes is ) no. Do you a contempt of account ( ) yes ( no Your failure to checkingwith this subpoena ( punishable as have a savings court and will make )you liable to 9. Does your wife (husband) have was issued for a maximum ( ) no; the party on whose behalf this subpoena a checking account? ( ) yes penalty of $50 and all damages sustained as a result of your failure to comply. yes ( ) no. Savings account? ( ) 10. Do you or your wife (husband) own stock or bonds? ( ) yes ( ) no; Jewelry? ( ) yes ( ) no. Witness, Honorable , ( yes 11. Do you or your wife (husband) own autos? ( ) yes ( ) no Trucks?one )of the(Justices of the ) no. yes ( Court in Trailers? ( )County,) no; Boat? ( ) yes ( ) ,no. day of 20 12. Number of Dependents _____________________________________ (Attorney must sign above and type name below) 1. Attorney(s) for Office and P.O. Address CR-2a [Rev. 6/04] Page 1 of 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: www.sanmateocourt.org American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. SUPERIOR COURT OF CALIFORNIA - COUNTY OF SAN MATEO Calendar No. ASSETS/INCOME: EXPENSES: : Your total monthly salary.............$___________ per month..............$___________ Plaintiff(s) Rent payment JUDICIAL SUBPOENA Wife/husband's total monthly Mortgage payment per month.......$___________ -against: salary...................................$___________ Food..........................................$___________ Other income per month..............$___________ Utilities:(gas, electric, phone, Amount of money in your garbage) ................................$___________ : possession now.......................$___________ Insurance...................................$___________ Amount of money at home...........$___________ Credit Payments.......................$___________ Defendant(s) : Child . . . .Amount .of .money .owed. to. you....$___________ . . . . . . . . . . . . care payments.....................$___________ ...... . ..... ... . ................. Amt of money due for tax refund..$___________ Clothing.....................................$___________ Amount of money in savings Medical/Dental............................$___________ account.................................$___________ Spousal support/alimony..............$___________ THE PEOPLE OF THE STATE OF NEW YORK Amount of money in spouse's Transportation............................$___________ savings account.......................$___________ Other (please specify...................$___________ TO Cash Value of insurance...............$___________ ________________________________________ Cash value of spouse's insurance...$___________ ________________________________________ Cash value of autos.....................$___________ ________________________________________ Cash value of ________________________________________ GREETINGS: trucks...................$___________ Cash value of trailers...................$___________ ________________________________________ WEof boats.....................$___________ and excuses being laid aside, you and each of you attend before COMMAND YOU, that all business Cash value ________________________________________ , the Honorable estate....................$___________ at the ________________________________________ Court Equity in real located at County of ASSETS/INCOME.........$___________ TOTAL TOTAL EXPENSES....................$___________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed The Court will make a determination of your ability to pay all or a portion of the cost of the attorney. or adjourned date, to testify and give evidence as a witness in this action on the part of the If the Court determines that you have the financial ability to pay all or some of those costs, the Court will order that you reimburse the County to the extent and in the manner that the Court finds reasonable. An order to reimburse the County for Court-appointed counsel fees will have the same force and effect as a judgment in a civil action and shall be subject to execution. Before the Court makes such an court and will entitled to liable to Your failur