FINANCIAL QUESTIONNAIRE TO ESTABLISH INDIGENCY - MUNICIPAL COURTS PART I GENERAL INFORMATION APPLICATION BY: DEFENDANT PARENT OR GUARDIAN (IF DEFENDANT IS UNDER 18) ASSIGNMENT OF COUNSEL FOR: PAYMENT OF FINES / PENALTIES IN INSTALLMENTS COMPLAINT NUMBER(S) OTHER ________ CHARGES CHARGES (continued) FIRST NAME LAST NAME MIDDLE INITIAL SEX DATE OF BIRTH Male / Female DRIVERS LICENSE NUMBER SOCIAL SECURITY NUMBER HOME STREET ADDRESS STATE STATE CITY HOME PHONE NUMBER ( ) PHONE NUMBER ( MARITAL STATUS Married Single Widowed ARE YOU ON BAIL FOR THIS CHARGE? Yes Separated ZIP HOW LONG AT THE ABOVE ADDRESS? - RELATIONSHIP EMERGENCY CONTACT NAME / ) - NUMBER OF THOSE YOU SUPPORT (Children or other family members) Divorced NAME AND ADDRESS OF SURETY AMOUNT $ No PART II EMPLOYMENT HISTORY ARE YOU NOW EMPLOYED? Yes CURRENT EMPLOYER, IF EMPLOYED; IF UNEMPLOYED, LAST EMPLOYER IF YES, LENGTH OF EMPLOYMENT No PHONE NUMBER EMPLOYER'S ADDRESS ( PART III POSITION HELD ) - ASSETS (include all jointly owned assets) GROSS WAGES PER (check one) $ Week WAS LAST YEAR'S INCOME TAX RETURN FILED? State SOURCE (welfare, workman's comp., social security) OTHER INCOME 2 Weeks $ Month RECEIVES ALIMONY OR CHILD SUPPORT Federal BY COURT ORDER Yes No Yes AMOUNT No $ CHECKING ACCOUNT: BANK ACCOUNT NUMBER BALANCE SAVINGS ACCOUNT: BANK ACCOUNT NUMBER BALANCE EQUITY PRESENT VALUE ADDRESS REAL ESTATE OWNED? Yes No Yes $ $ describe PERSONAL PROPERTY? $ $ PRESENT VALUE ITEM $ No describe PERSONAL PROPERTY? Yes PRESENT VALUE ITEM No $ describe YEAR VEHICLE Auto Truck MAKE MODEL PRESENT VALUE $ Motorcycle TOTAL ASSETS: PART IV EXPENSES AND LIABILITIES DO YOU HAVE A MORTGAGE? Yes No OUTSTANDING LOAN? Yes No DO YOU PAY RENT? Yes No NATURE OF THE LOAN $ DO YOU LIVE IN A HALFWAY HOUSE? Yes No MONTHLY PAYMENT $ MONTHLY PAYMENT $ BALANCE OWED $ BALANCE OWED $ American LegalNet, Inc. www.USCourtForms.com (OVER) OUTSTANDING LOAN? Yes NAME OF ATTORNEY COMPANY DOCTOR'S NAME MONTHLY PAYMENT HOSPITAL NAME MONTHLY PAYMENT COMPANY CREDIT CARDS? $ CREDIT LIMIT COMPANY CREDIT LIMIT $ COURT NAME MONTHLY PAYMENT COURT NAME MONTHLY PAYMENT $ BALANCE OWED $ $ No COMPANY BALANCE OWED MONTHLY PAYMENT $ $ No CHILD SUPPORT / ALIMONY PAYMENTS? BALANCE OWED MONTHLY PAYMENT $ $ No TYPE OTHER EXPENSES? MONTHLY PAYMENT TYPE MONTHLY PAYMENT BALANCE OWED $ $ No SUBSISTENCE (FOOD, CLOTHING, TRANSP.) Yes BALANCE OWED $ UTILITIES OWED? Yes $ OFFENSE(S) COURT FINES / PENALTIES OWED? Yes BALANCE OWED $ No Yes $ OFFENSE(S) COURT FINES / PENALTIES OWED? BALANCE OWED MONTHLY PAYMENT $ No $ MONTHLY PAYMENT $ No CREDIT CARDS? BALANCE OWED $ COMPANY CREDIT CARDS? Yes $ MONTHLY PAYMENT CREDIT LIMIT No Yes $ BALANCE OWED $ No Yes BALANCE OWED $ MEDICAL EXPENSES - HOSPITAL? Yes $ $ No Yes BALANCE OWED MONTHLY PAYMENT No MEDICAL EXPENSES - DOCTOR? Yes $ $ INSURANCE OWED? Yes BALANCE OWED MONTHLY PAYMENT No Yes $ $ MONEY OWED FOR ATTORNEY FEES? Yes BALANCE OWED MONTHLY PAYMENT NATURE OF THE LOAN No SUBSISTENCE EXPENSES $ $ No DOES ANYONE CONTRIBUTE TO THE PAYMENT OF THESE EXPENSES? Yes No IF YES, WHO? TOTAL AMOUNT CONTRIBUTED TOTAL MONTHLY PAYMENT TOTAL LIABILITIES $ $ $ PART V ATTORNEY INFORMATION CAN YOU AFFORD TO PAY FOR AN ATTORNEY? Yes No IF YES, HOW MUCH? ADDRESS NAME OF PRIVATE ATTORNEY WHO PAID FOR PRIVATE ATTORNEY? DID A PRIVATE ATTORNEY EVER REPRESENT YOU? Yes CAN RELATIVES OR FRIENDS HELP YOU PAY FOR AN ATTORNEY? No Yes $ AMOUNT OF RETAINER PAID PHONE NUMBER TOTAL ASSETS $ $ No - TOTAL LIABILITIES $ = $ PART VI CERTIFICATION PURSUANT TO NEW JERSEY COURT RULE 1:4-4(b) I CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE. I AM AWARE AND UNDERSTAND THAT IF ANY SUCH STATEMENTS MADE BY ME ARE WILFULLY FALSE, I AM SUBJECT TO PUNISHMENT. I AUTHORIZE THE COURT OR THE ADMINISTRATIVE OFFICE OF THE COURTS TO CONDUCT SUCH INVESTIGATION AS MAY BE NECESSARY TO VERIFY MY FINANCIAL STATUS, WHICH MAY INCLUDE BUT MAY NOT BE LIMITED TO A REVIEW OF MY CREDIT HISTORY, STATE AND/OR FEDERAL INCOME TAX RETURNS, BANK ACCOUNTS AND OTHER FINANCIAL INSTITUTION RECORDS. DATE SIGNATURE COUNSEL ASSIGNED Yes No DATE WITNESS, NAME AND POSITION APPLICATION FEE ASSESSED $ _________________ WAIVED PARITAL PAYMENT SCHEDULE _________________________________________________ COUNSEL DENIED - REASONS APPROVED BY JUDGE DATE The courthouse is accessible to those with disabilities. Please notify the court if you will require assistance. NOTES: American LegalNet, Inc. www.USCourtForms.com March 1998