Free CR-206 - Alaska

IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ( ) State of Alaska ( ) In the Matter of ( ) vs. CASE NO. Defendant or Minor FINANCIAL STATEMENT For Appointment of Counsel For Restitution Full Name Residence Address Mailing Address Home Phone:_____________ Work Phone:___________ Soc. Sec. No. Date of Birth

Are you under the age of 18? Yes No If yes, one of your parents must appear and provide financial information regarding the income of both parents. Have you filled out a financial statement to apply for a court-appointed attorney within the past 12 months? Yes No Was an attorney appointed for you? Yes No Are you receiving public assistance? SSI Food Stamps Medicaid Are you working now? Present Employer (If not now employed, state last employer and length of job.) Employer's Address Other Employers in Past Year Are you a seasonal worker? Yes No If yes, describe: Yes Yes No If so, check those you receive: ATAP Adult Public Assistance General Relief No If not, date last worked

1. DEFENDANT'S INCOME INFORMATION (after taxes, but before other deductions) Do not include income of spouse. If defendant is under age 18, list income of both defendant and parents. a. Current Monthly Income Wages $ Social Security $ Public Assistance $ Unemployment $ Other (specify) $ Total Monthly Income $

Social Security number is not mandatory. It may be used to identify your assets. Page 1 of 4 CR-206 (2/02)(cs) FINANCIAL STATEMENT AS 18.85 Crim R. 39 and 39.1

b. c. d. e. f.

Permanent Fund Dividends received in last 12 months ANCSA or other corporate dividends received in last 12 months Value of gifts received in last 12 months Total Income during last 12 months (Includes gifts, settlements, inheritances, wages, dividends, etc.)

$ $ $ $

Do you expect to receive other income in the next 6 months (for example, settlements, Yes No dividends, gifts, inheritances)? If yes, please specify Name Age Relationship

2. HOUSEHOLD MEMBERS (People who live with you)

3. MONTHLY HOUSEHOLD EXPENSES Expense Food Housing: Rent or Mortgage Utilities: Gas, Electricity Water, Garbage, Telephone Transportation (gas/bus) Car Payment Insurance Child Support or Alimony List Loans & Credit Card Debts: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount Balance Owed $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Past Due

Medical (not covered by insurance) Childcare: IRS Back Taxes Due TOTALS

ADJUSTMENTS TO EXPENSES: Yes No a. Are you married? If yes, list spouse's total income after taxes for the past 12 months (include gifts, settlements, inheritances, wages, dividends, etc.):

$

Note: For purposes of deciding appointment of counsel, expenses will be divided between spouses proportionate to each spouse's income.

Page 2 of 4 CR-206 (2/02)(cs) FINANCIAL STATEMENT

AS 18.85 Crim R. 39 and 39.1

b. Are any household expenses paid by someone other than you or your spouse (for example, by a roommate, parent, grandparent or child)? Yes No If yes, list: Name: Name: Relationship: Relationship: Amount $ Amount $

4. CASH AND ASSETS (things you own or are buying) Include all things you own by yourself and all things you own jointly with someone else. Value Cash Bank Acct./Checking Bank Acct./Savings Stocks, Bonds, CD's, Mutual Funds Retirement Plans Life Insurance (cash value) Land, Homes, Trailers Motor Vehicles (describe): $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ (-) Amount Still Owed

TV, Stereo, VCR Computer Equipment Snow Machines, Boats, ATVs, Airplanes, Motorcycles Jewelry, Precious Metals or Precious Stones Furs ........................................ Collections (Coins, Ivory, etc.) Tools ...................................... Guns ....................................... Sports Equipment (Kayaks, Skis, Scuba Gear, etc.) Fishing Gear........................... Quota Shares, IFQs ................ Businesses: Other: TOTALS

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Yes = $ No If yes, list the

Do you need any of the above items to earn your living? item and describe why you need it

Page 3 of 4 CR-206 (2/02)(cs) FINANCIAL STATEMENT

AS 18.85 Crim R. 39 and 39.1

5. CREDIT CARDS. List all your credit cards. Name of Card (Visa, MC, AMX) Credit Limit $ $ $ $ 6. OTHER EXPENSES Expense Cable TV Club Membership Fees Internet Fees Subscriptions (magazines, newspapers, etc.) Entertainment (dining out, (movies, theater, sporting events, etc.) Alcohol and Tobacco TOTAL Monthly Amount $ $ $ $ $ $ $ $ $ $ OATH WARNING: Making false statements under oath is a crime. I declare, under oath, that the above Financial Statement is true. Balance Owed $ $ $ $ $ $ $ $ Minimum Monthly Payment

Date Subscribed and sworn to or affirmed before me in on (date) .

Signature of Defendant or Parent , Alaska

(SEAL)

Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires:

Page 4 of 4 CR-206 (2/02)(cs) FINANCIAL STATEMENT

AS 18.85 Crim R. 39 and 39.1