COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. NAME OF VICTIM ON WHOSE BEHALF RESTITUTION IS ORDERED: :
NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:
Index No. Calendar No.
FOR COURT USE ONLY
: Plaintiff(s) -againstPEOPLE OF THE STATE OF CALIFORNIA vs.
: : : :
DEFENDANT'S STATEMENT OF ASSETS
Defendant(s) It is a misdemeanor to make any willful misstatement of material fact in completing this form (Pen. Code, § 1202.4(f)(4).) : ......................................................
(Attach additional sheets if the space provided below for any item is not sufficient.) PERSONAL INFORMATION 1. a. Name: f. Driver license number: b. THE PEOPLE OF THE STATE OF NEW YORK AKA: State of issuance: c. Date of birth: g. Home address: h. Home telephone no.: d. TO Social security number: e. Marital status: i. Employer's telephone no.: EMPLOYMENT 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):
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court locatedsources of income (specify): at b. County of If not employed, names and addresses of all in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the
How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify): What is your gross pay each pay period? $ What is your take-home pay each pay period? $ Your failure to comply with this subpoena is punishable as address of the court and employer, you liable If your spouse earns any income, give the name of your spouse, the name and a contempt ofbusiness or will makejob title, and to the or office whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a divisionparty on (specify):
4. 5. 6. 7.
result of your failure to comply.
8. Other sources of income (specify):
Witness, Honorable Court in County,
, one of the Justices of the day of , 20
CASH, BANK DEPOSITS 9. How much money do you have in cash? $ 10. How much other money do you have in banks, savings and loans, credit unions, and other financial institutions either in your own (Attorney must sign above and type name below) name or jointly (list):
Name and address of financial institution Account number Individual or joint? Balance
b. c. $ $
Office and P.O. Address PROPERTY 11. List all automobiles, other vehicles, and boats owned in your name or jointly: Legal owner if different
Make and year Value from registered owner Amount owed
a. b. c.
Adopted for Mandatory Use Judicial Council of California CR-115 [New July 1, 2000]
Telephone No.: Facsimile No.: E-Mail Address: (Continued on reverse) DEFENDANT'S STATEMENT Mobile Tel. No.: OF ASSETS
$ $ $
$ $ $
Penal Code, § 1202.4(f)
American LegalNet, Inc. www.USCourtForms.com
PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT:
List all real estate owned in your name or jointly:
Address of real estate Fair market value Amount owed
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):
Description Value Address where property is located
a. $ b. $ c. $ ASSETS 14. List all other assets, including stocks, bonds, mutual funds, and other securities (specify):
Is anyone holding assets for you? Yes. person or entity holding each asset (specify):
If yes, describe the assets and give the name and address of the
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? Yes. No. If yes, give the name and address of each person or entity who received any asset and describe each asset (specify):
DEBTS 17. Loans (give details):
Taxes (give details):
Support arrearages (attach copies of orders and statements): Credit cards (give creditor's name and address and the account number):
Other debts (specify):
(TYPE OR PRINT NAME)
I, (name): in the (specify language): the form and he/she completed the form. Date:
, 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
(TYPE OR PRINT NAME) CR-115 [New July 1, 2000]
DEFENDANT'S STATEMENT OF ASSETS