ATTORNEY OR PARTY WITHOUT ATTORNEY ( Name, State Bar number, and address ): Name: Street Address: City, State, Zip: TELEPHONE NO: FAX NO. (Optional) E - MAIL ADDRESS ( Optional ): ATTORNEY FOR ( Name ): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ 701 Ocean Street, Room 120 Santa Cruz, 95060 Santa Cruz Branch THE PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT: DEFENDANT FINANCIAL ELIGIBILITY STATEMENT FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT CASE NUMBER Form Adopted for MANDATORY USE Superior Court of Santa Cruz County SUPCR 1127 Rev 0 3/0 8 /18 DEFENDANT FINA N CIAL ELIGIBILTY STATEMENT FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT Page 1 of 2 Penal Code 247987.8 CASE NUMBER: SUPCR 1127 1. Defendant Personal Information Street Address (include house and unit no. ): City: State: Zip: Date of Birth: Phone Number: Marital Status: Spouse Name (if applicable): Number of Dependents: 2. Defendant Employment Information Are You Employed : Yes No (If No, is job pending Yes No) How Long Employed (Y rs / Mos ): Name of E mployer: Gross Pay Per Month: $ Spouse Gross Pay Per Month : $ Spouse Employer : 3. Defendant Other Income Information Do you receive income from sources other than employment? Yes No Source of income: Amount of monthly income: $ 4. Defendant Financial Information Total Monthly Income (All Sources + Gross Pay ): $ Total Monthly Expenses: $ Personal Savings and/or Assets: Yes No If Yes , How Much: $ Do You Own Real Estate or a Home: Yes No If Yes, what is the Value? $ Address es of A ll Property: P lease explain means of support if income is less than expenses: American LegalNet, Inc. www.FormsWorkFlow.com PEOPLE OF THE STATE OF CALIFORNIA v s. DEFENDANT: CASE NUMBER: Form Adopted for MANDATORY USE Superior Court of Santa Cruz County SUPCR 1127 Rev 0 3/0 8 /18 DEFENDANT FINA N CIAL ELIGIBILTY STATEMENT FOR APPOINTMENT OF COUNSEL AND REIMBURSEMENT Page 2 of 2 Penal Code 247987.8 CASE NUMBER: 5. Defendant understands that they may be responsible to pay a $50 appointment fee : Yes 6. Eligibility for Appointment of Counsel and Notice to Defendant : If an attorney is appointed to represent you and your case results in a felony or misdemeanor conviction, the Court may hold a hearing at the end of the criminal proceeding to determine your ability to pay all or a part of the cost associated with the le gal assistance provided to you. You could be required to pay the costs of any appointed attorney in make an inquiry into your ability to pay before the hear ing. Any court order to pay for legal fees will have the same force and effect as a judgment in a civil action and will be subject to execution. I declare under penalty of perjury that the foregoing is true and correct and that I understand the informat ion described in paragraph s number five (5) and six (6) , and that this declaration was executed on: Date : at (County) , California. Signature of Defen dant American LegalNet, Inc. www.FormsWorkFlow.com