Free cc293.p65 - Michigan

Approved, SCAO

Original - Circuit court 1st copy - Prosecutor 2nd copy - Defendant

STATE OF MICHIGAN CIRCUIT COURT COUNTY
Court address

AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT

CASE NO. COURT OF APPEALS: CIRCUIT COURT:
Court telephone no.

Defendant name, address, and telephone no.

THE PEOPLE OF THE STATE OF MICHIGAN

v

The following is information concerning my present financial status. 1. RESIDENCE Rent 2. MARITAL STATUS Single

Own

Live with parents

Room/Board

Prison
Number

Married

Divorced

Separated

Dependents:
Number

3. INCOME a. Employer name and address

b. Length of employment

c. Average pay weekly Gross: $

monthly

every two weeks Net: $

d. Other income (State monthly amount and source, such as DSS, VA, rent, pensions, spouse, unemployment, etc. If no income, state NONE.)

4. ASSETS (State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc. If no assets, state NONE. Attach an account statement
and certification for assets in prisoner accounts.)

5. OBLIGATIONS (Itemize monthly rent, installment payments, mortgage payments, child support, etc.)

Signature

Subscribed and sworn to before me on
Date

, Signature:
Notary public

County, Michigan

My commission expires:
Date

Notary public, State of Michigan, County of
Administrative Order 2003-03 CC 293 (5/07)

AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT