Fill and Sign the Ca Assets Form

It is a misdemeanor to make any willful misstatement of material fact in completing this form (Pen. Code, § 1202.4(f)(4).)––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– C R - 11 5 NA ME OF V I C TI M ON W H OS E B E HA L F R E S T I TU T I ON I S ORD E RE D : F OR C OUR T U S E ONLY NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PEO PLE O F THE STATE OF CALIFO RNIA v s. DEFENDANT: D E F E N D A N T ' S S TAT E M E N T O F A S S E T S CA S E NU MB E R : (Attach additional sheets if the space provided below for any item is not sufficient.) PERSONAL INFORMATION 1 . a . N a m e : f. Driver license number: b. A K A : State of issuance: c. Date of birth: d. Social security number: e. Marital status: g. Home address: h. Home telephone no.: i. Employer's telephone no.: EMPLOYMEN T 2. What are your sources of income and occupation? (Provide job title and name of division or office in which you work.) 3. a. Name and address of your business or employer (include address of your payroll or human resources department, if different): b. If not employed, names and addresses of all sources of income (specify): 4. How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify): 5. What is your gross pay each pay period? $ 6. What is your take-home pay each pay period? $ 7. If your spouse earns any income, give the name of your spouse, the name and address of the business or employer, job title, and division or office (specify): 8. Other sources of income (specify): CASH, BANK DEPOSITS 9. H ow muc h money do y o u h av e i n c as h? $ 1 0. How much other money do you have in banks, savings and loans, credit unions, and other financial institutions either in your own name or jointly (list): name and address of financial institution Account number individual or joint Balanc e a . $ b . $ C . $ PROPERT Y 11. List all automobiles, other vehicles, and boats owned in your name or jointly: Legal owner if different Make and year Valu e r e g i s t e r e d o w n e r Amount owed a . $ $ $ b . C . $ $ $ (Continued on reverse) Adopted for Mandatory Use Judicial Council of California CR-1 1 5 [New July 1, 2000] DEFENDANT'S STATEM ENT O F ASSETS Penal Code, § 1202.4(f)electronic form ã 1999 WWW.LawCA.co m Law Publishers ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––– –– ––– –– ––––– ––– –– ––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –––––PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT: CA S E NU MB E R : 12. List all real estate owned in your name or jointly: Address of real estate Fair market value Amount owed a . $ $ b . $ $ OTHER PERSONAL PROPERTY (Do not list household furniture and furnishings, appliances, or clothing.) 13. List anything of value not listed above owned in your name or jointly (continue on attached sheet if necessary): Descriptio n Valu e Address where property is located a . b . C . $ $ $ ASSET S 14. List all other assets, including stocks, bonds, mutual funds, and other securities (specify): 1 5. Is anyone holding assets for you? Ye s. N o. If yes, describe the assets and give the name and address of the person or entity holding each asset (specify): 16. Except for attorney fees in this matter and ordinary and routine household expenses, have you disposed of or transferred any assets since your arrest on this matter? Ye s. N o. If yes, give the name and address of each person or entity who received any asset and describe each asset (specify): DEBT S 17. Loans (give details): 18. Taxes (give details): 19. Support arrearages (attach copies of orders and statements): 20. Credit cards (give creditor's name and address and the account number): 2 1. Other debts (specify): Dat e: (TYPE OR PRINT NAME) (SIGNATURE) 1, (name): in the (specify language): , a certified interpreter, having been duly sworn, truly translated this form to the defendant language. The defendant indicated that he/she understood the contents of the form and he/she completed the form. Dat e: (TYPE OR PRINT NAME) (SIGNATURE) CR-1 15 [New July 1, 2000] DEFENDANT'S STATEMENT OF ASSETS P a g e t woelectronic form ã 1999 WWW.LawCA.co m Law Publishers