Financial Affidavit

FINANCIAL AFFIDAVIT
Personal Information
Name:*

First NameLast Name
Case Number(s):
List all cases which you have delinquent fines.
Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone:*
Email Address:
Social Security Number:
Date of Birth:*

MonthDayYear
Date
Driver's License Number:
Driver's License State:

Street Address

Street Address Line 2

CityState

Zip Code
Income Information
Are you employed?

YesNo
Employer Name:
Employer Phone:
Employer Address:
Monthly Income Amount (Gross):
Amount before taxes are deducted.
Payment Frequency:

WeeklyEvery two weeksMonthly
Household Size:
Household Income:
Is anyone help pay monthly expenses?

YesNo
Other Sources of household income:

MedicaidSocial SecurityOther
Miscellaneous Information
Number of Dependents:
Do you pay child support?

YesNo
How much child support do you pay per month?
Do you have bank accounts?

YesNo
Name of bank(s):
Do you have pending criminal charges?

YesNo
Pending criminal case numbers:
Is your license suspended?

YesNo
Are you interested in reinstating your drivers license?

YesNo
Do you have a vehicle registered in your name?

YesNo
Verification
I certify under penalty of perjury that the information on this financial affidavit is true and correct.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

FINANCIAL AFFIDAVIT