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Financial Questionnaire To Establish Indigency Form. This is a New Jersey form and can be use in Municipal Court Service Statewide.
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Tags: Financial Questionnaire To Establish Indigency, New Jersey Statewide, Municipal Court Service
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
$
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(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