Financial Questionnaire to Establish Indigency (Eng)

DefendantParent or Guardian if Defendant is Under 18 or Incompetent

Indigent Defense Services*Installment Payment of Fines/Penalties

*Note: if you are applying for indigent defense services, you may be charged with an application fee.

YesNo

If you answered "Yes" to all of the above 3 questions, go to Part VII and complete the Certification.

Complaint Number(s)

Number of Co-Defendants

Charges

Name

Last Name First NameMiddle Initial

Eye Color

MaleFemale

Date of Birth

Date

Social Security Number

Driver's License Number

State

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone Number

How long at the above address?

Number of those you support (Children or other family members)

FederalStateNone

YesNo

If yes, name and address of bail bond agency or person who posted bail

Amount Posted

YesNo

If yes, length of employment?

Current employer, if employed. If unemployed, last employer and date last employed.

Employer’s Address

Phone Number

Position Held

Gross Wages (before all deductions for taxes, etc.)

Week2 WeeksMonth

Other Income Received Monthly (for example: welfare, social security, unemployment compensation, worker's comp, disability pension).

YesNo

Amount received monthly.

YesNo

If yes, who?

Total amount contributed monthly.

Monthly Income - All Sources

Monthly Income - All Sources

Checking Account: Bank

Account Number

Balance

Savings Account: Bank

Bank Account Number

Balance

Other Cash Available

Amount Cantidad

YesNo

Address

Describe

Current Value

Address

Describe

Current Value

Year

Make

Model

Current Value

YesNo

Item

Describe

Current Value

Total Assets

YesNo

Monthly payment

Balance owed

YesNo

Total monthly payment

Total balance owed

YesNo

Total monthly payment

Total balance owed

YesNo

Total monthly payment

Total balance owed

YesNo

Credit Limit

Total monthly payment

Total balance owed

YesNo

Total monthly payment

Total balance owed

YesNo

Total monthly payment

Total balance owed

YesNo

Monthly Amount

Living expenses owed

YesNo

Total monthly payment

Total balance owed

Total Liabilities

Total monthly payment

Total Liabilities

Total Net Worth

Total Assets

Total Liabilities

Total Net Worth

YesNo

If yes, how much?

YesNo

Name of Attorney

Address

Phone number

Who paid for attorney?

Amount Paid

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, wage records, bank accounts and other financial institution records.

Signature

Date

Witness, Name and Position

Date

I certify that the foregoing statements made by me are true. I am aware and understand that if any of the foregoing statements made by me are willfully false, I am subject to punishment.

Signature

Date

YesNo

AssessedWaivedPartial Payment Schedule

Assessed

Partial Payment Schedule Plan

Counsel Denied - Reasons

YesNo

Signature

Date

Financial Questionnaire to Establish Indigency

Part II – Employment History

Part III – Income and Assets (include all assets you own by yourself or with someone else)

Part IV – Expenses and Liabilities

Part V – Attorney Information

Part VI– Authorization

Part VII – Certification Pursuant to New Jersey Court Rule 1:4-4(b)

For Court Use Only