Fill and Sign the Financial Questionnaire to Establish Indigency New Justia Form

PART I GENERAL INFORMATION Yes No VEHICLE Auto Truck Motorcycle MAKE MODEL PRESENT VALUE $ YEAR describe FINANCIAL QUESTIONNAIRE TO ES TABLISH INDIGENCY - MUNICI PAL COURTS (OVER) EQUITY PRESENT VALUE $ $ PRESENT VALUE $ PERSONAL PROPERTY? Y es PRESENT VALUE $ ITEM describe No REAL ES TATE OWNED? Yes No describe PERSONAL PROPERTY? ITEMADDRESS WAS LAST YEAR'S INCOME TAX RETURN FILED? Federal State RECEIVES ALIMONY ORCHILD SUPPORT Y es No CHECKING ACCOUNT: BANK ACCOUNT NUMBER BALANCE $ SAVINGS ACCOUNT: BANK ACCOUNTNUMBER BALANCE $ BY COURT ORDER Yes NoAMOUNT $ POSITION HELD PART III ASSETS (include all jointly owned assets) GROSS WAGES $ Week Month PER (check one) 2 Weeks OTHER INCOME $ SOURCE (welfare, workman's comp.,social security) ( ) - PHONE NUMBER EMPLOYER'S ADDRESS PART II EMPLOYMENT HISTORY ARE YOU NOW EMPLOYED? Yes No IF YES, LENGTH OFEMPLOYMENT CURRENT EMPLOYER, IF EMPLOYED; IF UNEMPLOYED, LAST EMPLOYER ARE YOU ON BAIL FOR THIS CHARGE? Yes No AMOUNT $ NAME AND ADDRESS OF SURETY Married Single Widowed Separated Divorced PHONE NUMBER RELATIONSHIP EMERGENCY CONTACT - NAME MARI TAL STATUS LAST NAME MIDDLE INITIAL FIRST NAME DA TE OF BIRTH SEX Male Female / / ZIP ( ) - STATE SOCIAL SECURITY NUMBER HOME PHONE NUMBER CHARGES(continued) CHARGES DRIVERSLICENSENUMBER ( ) - STATE CITY HOME STREET ADDRESS HOW LONG AT THE ABOVEADDRESS? NUMBER OF THOSE YOU SUPPORT (Children or other family members) COMPLAINT NUMBER(S) $ TOTAL ASSETS: Y es No DO YOU HAVE A MORTGAGE? Yes No DO YOU PAY RENT? Yes No DO YOU LIVE IN A HALFW AY HOUSE?MONTH LY PAYMENT $ BALANCE OWED $ Yes No OUTS TANDING LOAN? NATURE OF THE LOAN BALANCE OWED $ MONTH LY PAYMENT $ PART IV EXPENSES AND LIABILITIES PA YMENT OF FINES / PENA LTIES IN INSTALLMENTS ASSIGNMENT OF COUNSEL PARENT OR GUARDIAN (IF DEFENDANT IS UNDER 18) DEFENDANT APPLIC ATION BY: FOR : OTHER ________ CAN RELATIVES OR FRIENDS HELP YOU PAY FOR AN ATTORNEY? Yes No COURT FINES / PENA LTIES OWED? BALANCE OWED $ OFFENSE(S) Yes No BALANCE OWED $ Yes No UTILITIES OWED? BALANCE OWED $ COM PANY Yes No CHILD SUPPORT / ALIMONY PAYMENTS? BALANCE OWED $ COURT FINES / PENA LTIES OWED? OFFENSE(S) $ $ Yes No SUBSISTENCE (FOOD, CLOTHING, TRANSP.) $ CAN YOU AFFORD TO PAY FOR AN ATTORNEY? NAME OF PRI VATE ATTORNEY ADDRESS WHO PAID FOR PRI VATE ATTORNEY? I CERTIFY THAT THE FOREGOING S TATEMENTS MADE BY ME ARE TRUE. I AM AWARE AND UNDERS TAND THAT IF ANY SUCH S TATEMENTS MADE BY ME ARE WILFUL LY FALSE, I AM SUBJECT TO PUNISHMEN T. I AUTHORIZE THE COURT OR THE ADMINISTR ATIVE OFFICE OF THE COURTS TO CONDUCT SUCH INVESTIG ATION AS M AY BE NECESSARY TO VERIFY MY FINANCIAL S TATUS, WHICH MAY INCLUDE BUT M AY NOT BE LIMITED TO A REVIEW OF MY CREDIT HISTOR Y, STATE AND/OR FEDERAL INCOME TAX RETURNS, BANK ACCOUNTS AND OTHER FINANCIAL INSTITUTION RECORDS. PHONE NUMBER Yes No OTHER EXPENSES? TYPE TYPE BALANCE OWED SUBSISTENCE EXPENSES PART VI CERTIFIC ATION PURSUANT TO NEW JERSEY COURT RULE 1:4-4(b) DOES AN YONE CONTRIBUTE TO THE PA YMENT OF THESE EXPENSES? Yes No IF YES, WHO? COURT NAME COURT NAME MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ $ March 1998 PART V ATTORNEY INFORMATION TOTAL AMOUNT CONTRIBUTED $ $ TOTAL LIABILITIES $ $ Y es No OUTS TANDING LOAN? NATURE OF THE LOAN BALANCE OWED $ Yes No MONEY OWED FOR ATTORNEY FEES? BALANCE OWED $ NAME OF ATTORNEY Yes No INSURANCE OWED? BALANCE OWED $ COM PANY Yes No MEDICAL EXPENSES - DOCTOR? BALANCE OWED $ DOCTOR'S NAME Yes No MEDICAL EXPENSES - HOSPI TAL? BALANCE OWED HOSPI TAL NAME MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ MONTH LY PAYMENT $ Yes No CREDIT CARDS? BALANCE OWED $ COMPANY CREDIT LIMIT$ $ MONTH LY PAYMENT $ Y es No CREDIT CARDS? BALANCE OWED $ COMPANY CREDIT LIMIT$ MONTH LY PAYMENT $ Y es No CREDIT CARDS? BALANCE OWED $ COMPANY CREDIT LIMIT $ MONTH LY PAYMENT $ TOTAL MONTH LY PAYMENT TOTAL ASSETS AMOUNT OF RE TAINER PAID Yes No Yes No No DID A PRIVATE ATTORNEY EVER REPRESENT YOU? Y es IF YES, HOW MUCH? $ SIGNATURE DA TE TOTAL LIABILITIES APPROVED BY JUDGE Y es No COUNSEL ASSIGNED The court house is accessible t o t hose w it h disabilit ies. Please not if y t he court if y ou w ill require assist a nce. DATE $ -= WITNESS, NAME AND POSITION DA TE ASSESSED $ _________________ WAIVED APPLIC ATION FEE PARITAL PAYMENT SCHEDULE _________________________________________________ COUNSEL DENIED - REASONS NOTES: