Document Text
--- Document: Public Defender Application Document ---
LSIANTE
FINANCIAL QUESTIONNAIRE TO
ESTABLISH INDIGENCY - MUNICIPAL COURTS
PARTI-GENERAL INFORMATION
APPLICATION BY:
FOR:
DEFENDANT
PARENT OR GUARDIAN IF DEFENDANT IS UNDER 18 OR INCOMPETENT
INDIGENT DEFENSE SERVICES*
INSTALLMENT PAYMENT OF FINES/PENALTIES
NOTE: IF YOU ARE APPLYING FOR INDIGENT DEFENSE SERVICES, YOU MAY BE CHARGED WITH AN APPLICATION FEE.
ARE YOU RECEIVING WELFARE OR
PARTICIPATING IN ANOTHER GOVERNMENT
BASED INCOME MAINTENANCE PROGRAM?
COMPLAINT
NUMBER(S)
CHARGES
Yes
No
ARE YOU ONLY COMPLETING
THIS FORM FOR INSTALLMENT
PAYMENTS OF YOUR FINE?
Yes
No
ARE YOU ONLY CHARGED
WITH TRAFFIC OR
PARKING OFFENSES?
Yes
No
IF YOU ANSWERED "YES" TO ALL OF THE ABOVE 3 QUESTIONS, GO TO PART VI AND COMPLETE CERTIFICATION.
NUMBER OF
CO-DEFENDANTS
LAST NAME
SOCIAL
SECURITY
NUMBER
HOME STREET
ADDRESS
FIRST NAME
MIDDLE INITIAL
EYE COLOR
Male
DATE OF BIRTH
Female
DRIVER'S
LICENSE
NUMBER
STATE
Single
Widowed
MARITAL STATUS
Married
HAVE YOU POSTED BAIL FOR
THIS CHARGE?
Yes
No
Separated
NAME AND ADDRESS OF BAIL
BOND AGENCY OR PERSON
WHO POSTED BAIL
PART II EMPLOYMENT HISTORY
ARE YOU NOW EMPLOYED?
Yes
No
IF YES,
LENGTH OF
EMPLOYMENT
EMPLOYER'S ADDRESS
CITY
STATE
ZIP
HOME PHONE NUMBER
(
Divorced
)
NUMBER OF THOSE YOU
SUPPORT (Children or
other family members)
HOW LONG AT
THE ABOVE
ADDRESS?
WHICH INCOME TAX
RETURNS DID YOU
FILE LAST YEAR?
Federal
State
None
AMOUNT POSTED
CURRENT EMPLOYER, IF EMPLOYED;
IF UNEMPLOYED, LAST EMPLOYER AND
DATE LAST EMPLOYED
PHONE NUMBER
(
)
POSITION HELD
PART III - INCOME AND ASSETS (include all assets you own by yourself or with someone else)
GROSS WAGES
(before all deductions
for taxes, etc.)
$
DO YOU RECEIVE
ALIMONY OR
CHILD SUPPORT?
DOES ANYONE CONTRIBUTE TO THE
PAYMENT OF YOUR EXPENSES?
Yes
No
PER
Week
2 Weeks
Month
OTHER INCOME RECEIVED MONTHLY
(for example: welfare, social security, unemployment
compensation, worker's comp, disability pension)
$
BY COURT ORDER?
AMOUNT
Yes
No
Yes
No
IF YES, WHO?
CONTRIBUTED
MONTHLY
RECEIVED
MONTHLY
$
TOTAL AMOUNT
$
CHECKING ACCOUNT:
BANK
SAVINGS ACCOUNT:
BANK
OTHER CASH AVAILABLE
REAL ESTATE OWNED?
Yes
VEHICLE/VESSEL
Auto
ADDRESS
No
Describe
Truck
OTHER PERSONAL PROPERTY?
Yes
No
Motorcycle
Moped
ITEM
Describe
ACCOUNT
NUMBER
ACCOUNT
NUMBER
ADDRESS
Describe
YEAR
MAKE
MODEL
Boat
$
MONTHLY INCOME-ALL SOURCES
$
BALANCE
$
BALANCE
$
AMOUNT
$
CURRENT VALUE
$
CURRENT VALUE
$
CURRENT VALUE
$
TOTAL ASSETS
$
(OVER)
PART IV - EXPENSES AND LIABILITIES
DO YOU HAVE A MORTGAGE?
Yes
No
DO YOU PAY RENT?
Yes
No
DO YOU LIVE IN A HALFWAY HOUSE?
MONTHLY PAYMENT
No
Yes
No
$
BALANCE OWED
$
TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU HAVE OUTSTANDING LOAN(S) (CAR, HOME. PERSONAL, ETC.)?
Yes
No
$
$
TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU OWE INSURANCE PREMIUMS AND/OR SURCHARGES?
Yes
No
$
$
TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU OWE MEDICAL EXPENSES-DOCTOR/HOSPITAL/OTHER?
Yes
No
$
$
CREDIT LIMIT TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU OWE CREDIT CARD BALANCES?
Yes
No
$
$
$
TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU OWE COURT FINES/PENALTIES/COSTS?
Yes
No
$
$
TOTAL VIONTHLY PAYMENT
TOTAL BALANCE OWED
ARE YOU REQUIRED TO PAY CHILD SUPPORT AND/OR ALIMONY?
Yes
No
$
$
DO YOU PAY FOR LIVING EXPENSES (FOOD, CLOTHING. UTILITIES.
TRANSPORTATION, ETC.)?
MONTHLY AMOUNT
LIVING EXPENSES OWED
Yes
No
$
$
TOTAL MONTHLY PAYMENT
TOTAL BALANCE OWED
DO YOU OWE MONEY FOR ATTORNEY FEES?
Yas
No
$
$
TOTAL MONTHLY PAYMENT
TOTAL LIABILITIES
TOTAL LIABILITIES
$
$
TOTAL ASSETS
TOTAL LIABILITIES
TOTAL NET WORTH
TOTAL NET WORTH
$
-
$
=
$
PART V - ATTORNEY INFORMATION
CAN YOU AFFORD TO FAY
FOR AN ATTORNEY?
Yes
No
NAME OF ATTORNEY
IF YES, HOW
MUCH?
$
CAN PARENTS, GUARDIANS,
RELATIVES OR FRIENDS HELP
YOU PAY FOR AN ATTORNEY?
DID A PRIVATE ATTORNEY
EVER REPRESENT YOU?
Yes
No
Yes
No
ADDRESS
PHONE NUMBER
WHO PAID FOR
ATTORNEY?
PART VI - AUTHORIZATION
AMOUNT PAID
$
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,
WAGE RECORDS, BANK ACCOUNTS AND OTHER FINANCIAL INSTITUTION RECORDS.
SIGNATURE
DATE
WITNESS, NAME AND POSITION
DATE
PART VII - 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 OF THE FOREGOING STATEMENTS MADE
BY ME ARE WILFULLY FALSE, I AM SUBJECT TO PUNISHMENT.
SIGNATURE
FOR COURT USE ONLY
COUNSEL ASSIGNED
Yes
No
APPLICATION FEE
ASSESSED 5
WAIVED
PARITAL PAYMENT SCHEDULE
COUNSEL DENIED-REASONS
SIGNATURE
No
APPROVED BY JUDGE
Yes
NOTES:
DATE
DATE
Please notify the court if you have a
disability and will require assistance.
Rev. November 2003