Ariz. R. Crim. P. form 5(a)
________________________________ COURT | ______________________ County, Arizona |
STATE OF ARIZONA Plaintiff | [CASE/COMPLAINT NO.] | |
-vs- | DEFENDANT'S | |
FINANCIAL | ||
STATEMENT | ||
(Confidential) | ||
Defendant (FIRST, MI, LAST) | ||
__________________________________ | ||
INSTRUCTIONS TO THE DEFENDANT: You are to answer the following questions so the Judge can decide whether to appoint an attorney to represent you and/or, if a bond is required, how much it should be, or any other matter relating to indigence. Use care in filling in your answers. If you need more space for any answer, note such and write on the back of the page. If you knowingly give false or misleading information, you may be punished for contempt of court or subjected to prosecution for fraud or perjury. | ||
1. | Full name: ________________________________________________ | |
2. | Check the appropriate box: [ ] Single [ ] Married, living w/ spouse [ ] Married but separated [ ] Divorced [ ] Widowed [ ] Partnered | |
3. | In addition to yourself, how many other adults do you support? __________ How many children? __________________ | |
INCOME: | ||
4. | List below in Column 1 the money that you are paid or receive each month. If you are married and are living with your spouse, list below in Column 2 the money that your spouse is paid or receives each month. If you are separated, divorced, widowed, partnered or single, leave Column 2 blank. | |
Column 1 | Column 2 | |||
Amount paid to Me Monthly | Amount paid to Spouse Monthly | |||
a. | Wages, Salaries, Self Employment Income | $_____________________ | $_____________________ | |
b. | Payroll deductions | $_____________________ | $_____________________ | |
c. | Unemployment compensation | $_____________________ | $_____________________ | |
d. | Welfare benefits | $_____________________ | $_____________________ | |
e. | Disability benefits | $_____________________ | $_____________________ | |
f. | Veteran's benefits | $_____________________ | $_____________________ | |
g. | Social Security benefits | $_____________________ | $_____________________ | |
h. | Worker's compensation | $_____________________ | $_____________________ | |
i. | Accident benefits | $_____________________ | $_____________________ | |
j. | Retirement benefits | $_____________________ | $_____________________ | |
k. | Allotment checks | $_____________________ | $_____________________ | |
l. | Interest | $_____________________ | $_____________________ | |
m. | Dividends | $_____________________ | $_____________________ | |
n. | Child support received | $_____________________ | $_____________________ | |
o. | Alimony or maintenance received | $_____________________ | $_____________________ | |
p. | Total of any other income received | $_____________________ | $_____________________ | |
Source: ________________ | ||||
TOTAL MONTHLY INCOME: | $_____________________ | $_____________________ | ||
ASSETS: | ||||
5. | Cash: List below the amounts of cash held or value of: | |||
a. | Cash on you, your spouse, or in your jail property, and at home | $_____________________ | ||
b. | Cash in banks, credit unions, and elsewhere | $_____________________ | ||
c. | Cash owed to you or to your spouse by others | $_____________________ | ||
d. | Stocks and bonds; insurance policy cash values | $_____________________ | ||
e. | Beneficial interest in a trust | $_____________________ | ||
6. | Personal Property: List below any valuable personal property you own and have not listed above which is not needed by you or your family for day-to-day living. | ||||
a. | Description ______________ | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
b. | Description _______________ | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
c. | Description _________________ | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
7. | Auto: Complete the following information about any motor vehicles (e.g.: cars, trucks, trailers, boats, airplanes, motorcycles) that you are buying, that you own, or in which you claim to have an interest. | ||||
a. | Make, Year and Model | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
b. | Make, Year and Model | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
8. | Real Estate: Complete the following information about any real property (your home, other land, or buildings) that you are buying, that you own, or in which you claim to have an interest. | ||||
a. | Location | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
b. | Location | $_____________________ | $_____________________ | $_____________________ | |
(value) | (owed) | (net value) | |||
TOTAL AVAILABLE ASSETS: | $_____________________ | ||||
EXPENSES: | ||||
9. | List below all monthly expenses not already deducted from your pay. | |||
a. | Rent or house payment | $_____________________ | ||
b. | Total cost of utilities (water, electric, gas, telephone, trash) | $_____________________ | ||
c. | Food | $_____________________ | ||
d. | Credit card payments | $_____________________ | ||
e. | Installment loan payments | $_____________________ | ||
f. | Charge account payments | $_____________________ | ||
g. | Motor vehicle payments | $_____________________ | ||
h. | Union dues | $_____________________ | ||
i. | Medical care costs (doctors, dentists, medicine) | $_____________________ | ||
j. | Child support and alimony | $_____________________ | ||
k. | Cost of baby-sitter | $_____________________ | ||
l. | Motor vehicle insurance, maintenance and gas | $_____________________ | ||
10. | Do you have any expenses (monthly or otherwise) not shown above? If yes, please list below. | |||
a. | _________________________ | $__________ | ||
(how often paid) | (how much) | |||
b. | _________________________ | $___________ | ||
(how often paid) | (how much) | |||
c. | _________________________ | $_________ | ||
(how often paid) | (how much) | |||
TOTAL MONTHLY EXPENSES: | $ | |||
11. | Are any of your expenses past due? If yes, please list below. | |||
a. | $___________________ | |||
(how often paid) | (how much) | |||
b. | $___________________ | |||
(how often paid) | (how much) | |||
c. | $_____________________ | |||
(how often paid) | (how much) | |||
12. | Do you have an attorney to help you with this case? [ ] Yes [ ] No | |||
If yes, what is his/her name: _______________ If no, are you planning to hire your own attorney? [ ] Yes [ ] No | ||||
13. | Do you want the Court to appoint an attorney (public defender) to help you with this case? [ ] Yes [ ] No | |||
a. | How much can you pay as a down payment for attorney fees? | $_______________________ | ||
b. | How much can you pay each month for attorney fees? | $________________________ | ||
14. | Oath under penalty of perjury: I have truthfully and completely given the information in this statement. I have not knowingly concealed, or in any way misrepresented, my financial resources. I am aware that I may be held in contempt of court, or prosecuted for perjury if I have made any false statements or misrepresentation, or concealment, or if I continue to accept the services of a court appointed attorney after my financial condition has materially changed without notifying my court appointed attorney. In any such case, I understand that this application may be used against me. | |||
I hereby make these representations under PENALTY OF PERJURY: | ||||
Date: ____________________________ | Defendant Signature: ________________________________ |
Witnessed by: _________________________ | Social Security No.: __________________________________ |
Form 5(a)
Ariz. R. Crim. P. form 5(a)