UNITED STATES DISTRICT COURT DISTRICT OF MAINE FINANCIAL DECLARATION CASE # AND NAME: NAME: ADDRESS: ___________________________________________________________________________________ PHONE #: ____________________________ MARITAL STATUS: Single Married __________________________________________ __________________________________________ Divorced __________________________________________ WARNING: NUMBER OF DEPENDENTS: ___________ The information you provide in order to obtain court-appointed representation is subject to the following limitations: (1) The attorney/client privilege may not apply; (2) The information is subject to being filed with the Court for future examination by the United States Attorney; (3) A false or dishonest answer could be punished as a crime; and (4) The form must be signed under penalty of perjury. ASSETS I. INCOME PRESENT EMPLOYER'S NAME: ______________________________________________________________ ADDRESS: ______________________________________________________________ MONTHLY WAGES: Gross ___________________ Net __________________________________ IF NOT CURRENTLY EMPLOYED: NAME OF YOUR PRIOR EMPLOYER: ___________________________________________________________ MONTH and YEAR YOU WERE LAST EMPLOYED: _______________________________________________ MONTHLY EARNINGS OF LAST EMPLOYMENT: ________________________________________________ SPOUSE'S EMPLOYER:________________________________________________________________________ MONTHLY WAGES: Gross ___________________ Net ____________________________________ OTHER INCOME: WELFARE: ________________ SOCIAL SECURITY (Amount Rec'd): ________________________ PENSION: _________________ OTHER: __________________________________________________ II. PROPERTY REAL ESTATE 1. HOME 2. OTHER VEHICLES 1. _________________ 2. _________________ VALUE _________________ _________________ VALUE _________________ _________________ MORTGAGE AMOUNT _____________________ _____________________ OWED _____________________ _____________________ NET EQUITY _________________ _________________ NET _________________ _________________ (COMPLETE REVERSE SIDE) American LegalNet, Inc. www.FormsWorkFlow.com III. OTHER ASSETS 1. CASH ON HAND ___________________ 2. CHECKING ACCOUNT ___________________ 3. SAVINGS ACCOUNT ___________________ 4. CREDIT UNION ___________________ 5. ACCOUNTS RECEIVABLE ___________________ 6. 7. 8. 9. JEWELRY STOCKS BONDS OTHER _____________________ _____________________ _____________________ _____________________ LIABILITIES I. REAL ESTATE LENDER 1. _________________________ 2. _________________________ 3. _________________________ II. MOTOR VEHICLES LENDER 1. _________________________ 2. _________________________ 3. _________________________ GENERAL DEBTS LENDER 1. _________________________ 2. _________________________ 3. _________________________ 4. _________________________ 5. _________________________ HOUSEHOLD EXPENSES 1. 2. 3. 4. 5. 6. RENT UTILITIES TELEPHONE GROCERIES CHILD SUPPORT ALIMONY ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ 7. TRANSPORTATION 8. CLOTHES 9. MEDICAL/DENTAL 10. TAXES 11. INSURANCE 12. OTHER ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ TOTAL OWED ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ TOTAL OWED ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ III. TOTAL OWED ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ IV. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. _______________________________ DATE ____________________________________________ SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com