UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE FINANCIAL DECLARATION CASE # AND NAME: ______________________________________________________________________________ NAME: __________________________________________ PHONE #: ____________________________ ADDRESS: __________________________________________ MARRIED: __________________________________________ NUMBER OF DEPENDENTS: ___________ WARNING: YES [ ] NO [ ] 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 EMPLOYER'S NAME: ______________________________________________________________ MONTHLY WAGES: Gross ___________________ Net ___________________________ WELFARE: ________________ SOCIAL SECURITY (Amount Rec’d): _______________ PENSION: _________________ OTHER: ________________________________________ SPOUSE'S EMPLOYER:_____________________________________________________________ MONTHLY WAGES: Gross ___________________ Net ___________________________ WELFARE: ________________ SOCIAL SECURITY (Amount Rec’d): _______________ PENSION: _________________ OTHER: ________________________________________ II. PROPERTY REAL ESTATE 1. HOME 2. OTHER 3. OTHER VEHICLES 1. _________________ 2. _________________ 3. _________________ VALUE _________________ _________________ _________________ MORTGAGE _________________ _________________ _________________ NET _________________ _________________ _________________ VALUE _________________ _________________ _________________ OWED _________________ _________________ _________________ NET _________________ _________________ _________________ 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 _____________________ _____________________ _____________________ _____________________ (COMPLETE REVERSE SIDE) USDCNH-15 (Rev 11-04) (Previous editions obsolete) American LegalNet, Inc. www.USCourtForms.com LIABILITIES I. REAL ESTATE LENDER 1. _________________________ 2. _________________________ 3. _________________________ II. MOTOR VEHICLES LENDER 1. _________________________ 2. _________________________ 3. _________________________ III. GENERAL DEBTS LENDER 1. _________________________ 2. _________________________ 3. _________________________ 4. _________________________ 5. _________________________ 6. _________________________ 7. _________________________ 8. _________________________ 9. _________________________ 10. _________________________ IV. TOTAL OWED ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ TOTAL OWED ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ TOTAL OWED ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ MONTHLY PAYMENTS ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ HOUSEHOLD EXPENSES 1. 2. 3. 4. 5. 6. 7. TELEPHONE ___________________ UTILITIES ___________________ CHILD SUPPORT ___________________ ALIMONY ___________________ CLOTHES ___________________ TRANSPORTATION___________________ INSURANCE ___________________ 8. GROCERIES 9. MEDICAL/DENTAL 10. SCHOOL 11. CHURCH 12. TAXES 13. RENT 14. OTHER ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. _______________________________ DATE REQUEST APPROVED: ( ) Date: _________________________ USDCNH-15 (Rev 11-04) (Previous editions obsolete) ____________________________________________ SIGNATURE REQUEST DISAPPROVED: ( ) _________________________________________ United States Magistrate Judge United States District Judge American LegalNet, Inc. www.USCourtForms.com