FINANCIAL STATEMENT ­ ELIGIBILITY DETERMINATION FOR INDIGENT DEFENSE SERVICES Commonwealth of Virginia Case No. ...................................................................... VA. CODE § 19.2-159 PRESUMPTIVE ELIGIBILITY [ ] I currently receive the following type(s) of public assistance in ....................................................................................................................................... CITY/COUNTY [ ] TANF $ ..................................................... [ ] Medicaid [ ] Supplemental Security Income $ .................................................. [ ] SNAP (food stamps) $ .................................................... [ ] Other (specify type and amount) ..................................................................... [ ] I currently do not receive public assistance. Names and address of employer(s) for defendant and spouse: Self ...................................................................................................................................................................................................................................................................... Spouse (not applicable if alleged victim) ............................................................................................................................................................................................ NET INCOME: Self Spouse Pay period (weekly, every second week, twice monthly, monthly) ................................ .......................... ........................... Net take home pay (salary/wages, minus deductions required by law) ......................... $ ....................... ........................... Other income sources (please specify) ...................................................................................................................................................................... .......................... $ ....................... EMPLOYMENT HISTORY: Were you employed at the time of your arrest? [ ] yes [ ] no If yes, my net take home pay was [ ] per week [ ] month If no, length of time since last employed? ...................................... Total wages earned last calendar year? $ ................................... $ ................................... COURT USE ONLY TOTAL INCOME $ ....................... $ ....................... $ ....................... + ........................... = ........................... ........................... A ASSETS: Cash on hand ......................................................................................................................................... Bank Accounts at: ............................................................................................................................... Any other assets: (please specify) ___________________________________________________________ with a value of ........................ $ ....................... $ ....................... ........................... ........................... Real estate ­ $ _______________________ NET VALUE Motor Vehicles { _________________________________ YEAR AND MAKE with net value of ........................ with net value of ........................ $ ....................... ........................... _________________________________ YEAR AND MAKE $ ....................... $ .......................... ........................... .............................. COURT USE ONLY Other Personal Property: (describe) ............................................................................................. . TOTAL ASSETS ................. $ .......................... + .............................. = B Number in household defendant has financial responsibility for, including defendant. EXCEPTIONAL EXPENSES (Total Exceptional Expenses of Family) Medical Expenses (list only unusual and continuing expenses) .................................................................. Court-ordered support payments/alimony ............................................................................................................ [ ] deducted from paycheck [ ] not deducted from paycheck Child-care payments (e.g. day care) ....................................................................................................................... Other (describe): ............................................................................................................................................................. ................................................................................................................................................................................................. $ .............................. $ .............................. $ .............................. } $ .............................. COURT USE ONLY This statement is made under oath. Any false statement may constitute a violation of law under Virginia Code § 19.2-161 and be subject to criminal penalty, including incarceration. TOTAL EXPENSES $ .............................. COLUMN "A" plus COLUMN "B" minus COLUMN "C" equals available funds = = C I hereby state that the above information is correct to the best of my knowledge. Name of defendant (type or print) ............................................................... DATE ................................................................................................................................. _________________________________________________________ SIGNATURE Sworn/affirmed and signed before me this day. ............................................................... DATE FORM DC-333 REVISED 10/11 _________________________________________________________ SIGNATURE _____________________________ TITLE American LegalNet, Inc. www.FormsWorkFlow.com