Super ior Court of the State of California COUNTY OF TULARE Collections Division Stephanie Cameron 221 S. Mooney Blvd., Room G - 28 Nocona Soboleski Court Executive Officer Visalia, California 93291 Assistant Court Executive Officer Jury Commissioner Tele phone: (559) 730 - 5000 Ability to Pay Income and Expense Form Monthly Expenses Monthly Income Mortgage/Rent $ Take-Home Pay (Self) $ Second Mortgage $ Take-Home Pay (Spouse) $ Utilities Unemployment $ Electric $ Gas $ $ Phone $ Water/Sewer/Trash $ Welfare $ Cable TV $ (Type) Food $ Retirement/Pension $ Vehicle Loan(s) $ Child Support $ Health/Life Insurance $ Alimony $ All Credit Cards $ Disability $ Loans (Personal/Student) $ $ Medical/Hospital/Dentist $ Accident Benefits $ Child Care $ Parents $ Total Monthly Expenses $ Total Monthly Income $ Verified by: Date: (Collector) Disposable Income: I Swear (affirm) under penalty of perjury that the preceding information is true and correct. I understand that providing false and/or incomplete information to the Superior Court Collection Division may result in further legal action against me. The Court has my permission to make any necessary inquiries to verify the information provided and to obtain any additional information required by the Court. Defendant's Signature Date: COL - 00 4 - 2017 - O Optional Form Revised - February 2018 American LegalNet, Inc. www.FormsWorkFlow.com