Declaration of Financial Status

1
Name* This field is required.
First Name
Last Name
2
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Case Number:* This field is required.
If you do not have your case number, you can enter your Citation number or zero's.
4
Phone Number:* This field is required.
Please enter a valid phone number.
5
Email:* This field is required.
Check your Email. You will receive information and documents at this email address.
6
Court:* This field is required.READ ONLY- This field is pre-filled for you. Please click next.
District
Justice
7
Judicial Branch:READ ONLY- This field is pre-filled for you. Please click next.
8
District:READ ONLY- This field is pre-filled for you. Please click next.
9
Court Address:READ ONLY- This field is pre-filled for you. Please click next.
10
Plaintiff:READ ONLY- This field is pre-filled for you. Please click next.
11
Defendant Name:* This field is required.READ ONLY- This field is pre-filled for you. Please click next.
First Name
Last Name
12
Judge:READ ONLY- This field is pre-filled for you. Please click next.
13
I request a court appointed lawyer. My date of birth is:* This field is required.
14
Marital Status:* This field is required.
Single
Married
Widowed
Divorced
15
Total Number of dependants/children:* This field is required.For each person you are legally required to support, list their age and your relationship to them.
16
Dependent #1* This field is required.What is the age of Dependent #1?
17
Dependent #1* This field is required.What is the relationship of Dependent #1 to you?
Son
Daughter
Step Son
Step Daughter
Brother
Sister
Mother
Father
Niece
Nephew
Aunt
Uncle
Other
18
Dependent #2* This field is required.What is the age of Dependent #2?
19
Dependent #2* This field is required.What is the relationship of Dependent #2 to you?
Son
Daughter
Step Son
Step Daughter
Brother
Sister
Mother
Father
Niece
Nephew
Aunt
Uncle
Other
20
Dependent #3* This field is required.What is the age of Dependent #3?
21
Dependent #3* This field is required.What is the relationship of Dependent #3 to you?
Son
Daughter
Step Son
Step Daughter
Brother
Sister
Mother
Father
Niece
Nephew
Aunt
Uncle
Other
22
Dependent #4* This field is required.What is the age of Dependent #4?
23
Dependent #4* This field is required.What is the relationship of Dependent #4 to you?
Son
Daughter
Step Son
Step Daughter
Brother
Sister
Mother
Father
Niece
Nephew
Aunt
Uncle
Other
24
Dependent #5* This field is required.What is the age of Dependent #5?
25
Dependent #5* This field is required.What is the relationship of Dependent #5 to you?
Son
Daughter
Step Son
Step Daughter
Brother
Sister
Mother
Father
Niece
Nephew
Aunt
Uncle
Other
26
More then 5 dependents:* This field is required.If you have more then 5 dependents/children, please list the additional ages and relationships here:
27
Are you Employed:* This field is required.
Yes
No
Self-Employed
28
Employer Name:* This field is required.
29
Hourly Rate:* This field is required.
30
Average Hours per Week:* This field is required.
31
Work Status:* This field is required.
Full Time
Part Time
32
If married, is you spouse employed:* This field is required.
Yes
No
33
Spouse Employer:* This field is required.
34
Hourly Rate:* This field is required.
35
Average hours per week:* This field is required.
36
Work Status:
Full Time
Part Time
37
Other income. If not employed, do you have income from another source?* This field is required.
Yes
No
Currently Employed
38
Retirement Income:
39
Alimony Income:
40
Child Support Income:
41
SSI/Disability Income:
42
Public Assistance Income:
43
Unemployment Income:
44
Other Income:
45
Total Income:READ ONLY- This field is pre-filled for you. Please click next.
Total pay from all sources during the last 6 months.
46
Assets in any location/state? (i.e. cash, savings, land, stocks, etc.)* This field is required.
Yes
No
47
Total Cash:
(savings or checking)
48
Total Value of Land, house(s), or real property in your name:
Include assets held for your benefit.
49
Total Market Value of Vehicles:
50
Make(s)/Model(s)
51
Total Retirement Accounts:
52
Stocks, Bonds & Notes:
53
Any other Items (list)
54
Total Assets:READ ONLY- This field is pre-filled for you. Please click next.
55
Debts: Creditors (to whom you owe money):* This field is required.Do you have debts with Creditors?
Yes
No
56
Number of Creditor Debt(s):How many creditors do you have debt with?
Creditor(s) 4 or more.
57
Total Owed:Creditor #1
Creditor 1
58
Monthly Payment:Creditor #1
Creditor 1
59
Collateral (auto, house, etc.):Creditor #1
Creditor 1
60
Total Owed:Creditor #2
Creditor 2
61
Monthly Payment:Creditor #2
Creditor 2
62
Collateral (auto, house, etc.):Creditor #2
Creditor 2
63
Total Owed:Creditor #3
Creditor 3
64
Monthly Payment:Creditor #3
Creditor 3
65
Collateral (auto, house, etc.):Creditor #3
Creditor 3
66
Additional Creditors:Please list additional creditor debts here. Be sure to include 1) Total Owed, 2) Monthly Payment amount and, 3) Collateral for that debt (i.e. auto, house, etc.), if any.
67
Monthly Expenses (i.e. housing, food, utilities, etc.):Do you have monthly Expenses?
Yes
No
68
Housing:
69
Food:
70
Utilities:
71
Transportation:
72
Debt Payments:
73
Medical:
74
School:
75
Clothing:
76
Necessities (list):
77
Child Support:
78
Alimony:
79
Other (include fines, fees, or restitution you are required to pay):
80
Attorney Fees you are required to pay from other cases:
81
Total Expenses:READ ONLY- This field is pre-filled for you. Please click next.
82
I have these extraordinary financial conditions that prevent me from hiring a private lawyer (explain):* This field is required.
83
I may be subject to criminal penalties for making any false statements in this declaration. I authorize the government agency that is responsible for providing lawyers to people who cannot pay in a criminal cases to contact me or request information from me or a third party to verify whether I can afford a private lawyer. I may be ordered to pay the cost of my court appointed lawyer if the court later determines that I am able to pay. I declare under criminal penalty under the law of Utah that everything stated in this document is true.

Signed at city, and state or country of where document was signed * (city, and state or country).
84
Signature Date:* This field is required.READ ONLY- This field is pre-filled for you. Please click next.
Date
Month
Day
Year
85
Defendant Signature:* This field is required.
Clear
86
Printed Name* This field is required.READ ONLY- This field is pre-filled for you. Please click SUBMIT.
First Name
Last Name
Should be Empty: