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FINANCIAL QUESTIONNAIRE TO ESTABLISH INDIGENCY - MUNICIPAL COURTS
PART I GENERAL INFORMATION
APPLICATION BY: FOR:
COMPLAINT NUMBER(S) CHARGES (continued) LAST NAME FIRST NAME MIDDLE INITIAL SEX DATE OF BIRTH

DEFENDANT

PARENT OR GUARDIAN (IF DEFENDANT IS UNDER 18) PAYMENT OF FINES / PENALTIES IN INSTALLMENTS
CHARGES

ASSIGNMENT OF COUNSEL

OTHER ________

Male Female

/
STATE

/

SOCIAL SECURITY NUMBER HOME STREET ADDRESS CITY

DRIVERS LICENSE NUMBER STATE

ZIP

HOME PHONE NUMBER

(
EMERGENCY CONTACT NAME MARITAL STATUS Married Single Widowed Separated Divorced RELATIONSHIP

)

(

HOW LONG AT THE ABOVE ADDRESS? PHONE NUMBER

)

-

NUMBER OF THOSE YOU SUPPORT (Children or other family members) AMOUNT

ARE YOU ON BAIL FOR THIS CHARGE? Yes No

NAME AND ADDRESS OF SURETY

$
IF YES, LENGTH OF EMPLOYMENT CURRENT EMPLOYER, IF EMPLOYED; IF UNEMPLOYED, LAST EMPLOYER PHONE NUMBER POSITION HELD

PART II EMPLOYMENT HISTORY
ARE YOU NOW EMPLOYED? Yes EMPLOYER'S ADDRESS No

(
PART III
GROSS WAGES

)

-

ASSETS (include all jointly owned assets)
PER (check one) Week 2 Weeks Month OTHER INCOME

$
WAS LAST YEAR'S INCOME TAX RETURN FILED? CHECKING ACCOUNT: BANK SAVINGS ACCOUNT: BANK REAL ESTATE OWNED? Yes No State

$
Yes No ACCOUNT NUMBER ACCOUNT NUMBER

SOURCE (welfare, workman's comp., social security) BY COURT ORDER Yes No AMOUNT

Federal

RECEIVES ALIMONY OR CHILD SUPPORT

$
BALANCE

$
BALANCE

$
PRESENT VALUE

ADDRESS describe ITEM describe

EQUITY

$

$
PRESENT VALUE

PERSONAL PROPERTY? Yes No

$
PRESENT VALUE

PERSONAL PROPERTY? Yes VEHICLE Auto Truck No

ITEM describe YEAR Motorcycle MAKE MODEL

$
PRESENT VALUE

$
TOTAL ASSETS:

PART IV EXPENSES AND LIABILITIES
DO YOU HAVE A MORTGAGE? Yes No DO YOU PAY RENT? Yes No DO YOU LIVE IN A HALFWAY HOUSE? Yes No MONTHLY PAYMENT

$
BALANCE OWED

$
MONTHLY PAYMENT

$
BALANCE OWED

OUTSTANDING LOAN? Yes No

NATURE OF THE LOAN

$

$
(OVER)

OUTSTANDING LOAN? Yes No

NATURE OF THE LOAN

MONTHLY PAYMENT

BALANCE OWED

$
NAME OF ATTORNEY MONTHLY PAYMENT

$
BALANCE OWED

MONEY OWED FOR ATTORNEY FEES? Yes No

$
COMPANY MONTHLY PAYMENT

$
BALANCE OWED

INSURANCE OWED? Yes No

$
DOCTOR'S NAME MONTHLY PAYMENT

$
BALANCE OWED

MEDICAL EXPENSES - DOCTOR? Yes No

$
HOSPITAL NAME MONTHLY PAYMENT

$
BALANCE OWED

MEDICAL EXPENSES - HOSPITAL? Yes CREDIT CARDS? Yes CREDIT CARDS? Yes CREDIT CARDS? Yes No No No No

$
COMPANY CREDIT LIMIT MONTHLY PAYMENT

$
BALANCE OWED

$
COMPANY CREDIT LIMIT

$
MONTHLY PAYMENT

$
BALANCE OWED

$
COMPANY CREDIT LIMIT

$
MONTHLY PAYMENT

$
BALANCE OWED

$
OFFENSE(S) COURT NAME

$
MONTHLY PAYMENT

$
BALANCE OWED

COURT FINES / PENALTIES OWED? Yes No

$
OFFENSE(S) COURT NAME MONTHLY PAYMENT

$
BALANCE OWED

COURT FINES / PENALTIES OWED? Yes UTILITIES OWED? Yes No No

$
COMPANY MONTHLY PAYMENT

$
BALANCE OWED

$
MONTHLY PAYMENT

$
BALANCE OWED

CHILD SUPPORT / ALIMONY PAYMENTS? Yes OTHER EXPENSES? Yes No TYPE No TYPE

$
MONTHLY PAYMENT

$
BALANCE OWED

$
MONTHLY PAYMENT

$
SUBSISTENCE EXPENSES

SUBSISTENCE (FOOD, CLOTHING, TRANSP.) Yes No

$
IF YES, WHO? TOTAL AMOUNT CONTRIBUTED TOTAL MONTHLY PAYMENT

$
TOTAL LIABILITIES

DOES ANYONE CONTRIBUTE TO THE PAYMENT OF THESE EXPENSES? Yes No

$
CAN RELATIVES OR FRIENDS HELP YOU PAY FOR AN ATTORNEY? No Yes ADDRESS

$

$
DID A PRIVATE ATTORNEY EVER REPRESENT YOU? Yes PHONE NUMBER

PART V ATTORNEY INFORMATION
CAN YOU AFFORD TO PAY FOR AN ATTORNEY? Yes No NAME OF PRIVATE ATTORNEY IF YES, HOW MUCH?

$

No

WHO PAID FOR PRIVATE ATTORNEY?

AMOUNT OF RETAINER PAID

TOTAL ASSETS

$

$

-

TOTAL LIABILITIES

$

=

$

PART VI CERTIFICATION PURSUANT TO NEW JERSEY COURT RULE 1:4-4(b)
I CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE. I AM AWARE AND UNDERSTAND THAT IF ANY SUCH STATEMENTS MADE BY ME ARE WILFULLY FALSE, I AM SUBJECT TO PUNISHMENT. I AUTHORIZE THE COURT OR THE ADMINISTRATIVE OFFICE OF THE COURTS TO CONDUCT SUCH INVESTIGATION AS MAY BE NECESSARY TO VERIFY MY FINANCIAL STATUS, WHICH MAY INCLUDE BUT MAY NOT BE LIMITED TO A REVIEW OF MY CREDIT HISTORY, STATE AND/OR FEDERAL INCOME TAX RETURNS, BANK ACCOUNTS AND OTHER FINANCIAL INSTITUTION RECORDS.
SIGNATURE DATE WITNESS, NAME AND POSITION DATE

COUNSEL ASSIGNED Yes No

APPLICATION FEE ASSESSED $ _________________ WAIVED PARITAL PAYMENT SCHEDULE _________________________________________________

COUNSEL DENIED - REASONS

APPROVED BY JUDGE

DATE

The courthouse is accessible to those with disabilities. Please notify the court if you will require assistance.

NOTES:

March 1998