Police Department Personal History Statement Form Page 13
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22Please provide the following information concerning your monthly income/payments
33.
Your salary (gross) _________________________
Real estate mortgage payment _________________________
Your salary (net) ___________________________
Rent payment ______________________________________
Spouse’s salary (gross) _______________________
Automobile loan payment(s) ___________________________
Spouse’s salary (net) ________________________
Other long term loan(s) _______________________________
Other income ______________________________
Credit cards/revolving credit __________________________
Other income ______________________________
Child Support ______________________________________
TOTAL MONTHLY NET INCOME: ___________
Other _____________________________________________
34.
Please provide the following information concerning your overall finances.
Assets
Liabilities
Checking _________________________________
Real estate Mortgage ________________________________
Savings __________________________________
Automobile loans ___________________________________
Personal property __________________________
Credit Cards _______________________________________
Real estate ________________________________
Student loans ______________________________________
Automobiles ______________________________
Other liabilities/loans ________________________________
Other assets _______________________________
_________________________________________________
TOTAL ASSETS: __________________________
TOTAL LIABILITIES: _______________________________
LEGAL:
Disclosure of Arrests and Convictions
Please disclose any of the following which occurred on or after your 15th birthday, even if the records were sealed, expunged,
dismissed or pardoned:
• ALL detentions or arrests, whether they resulted in a conviction or not
• ALL convictions
• ALL diversion programs that were not successfully completed
If more space is needed, continue on page 19-20.
35. Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion, questioned, finger-
printed, arrested, indicted, criminally charged, or convicted of any misdemeanor or felony offense in this state or in any
other legal jurisdiction (including offenses punishable under the Uniform Code of Military Justice)? . . . . . . Yes No
If yes, explain each incident.
A) Approximate Date ________________________
Arresting or Detaining Agency ___________________________________
Charge ________________________________________________________________________________________________
Disposition or Penalty ____________________________________________________________________________________
B) Approximate Date ________________________
Arresting or Detaining Agency ___________________________________
Charge ________________________________________________________________________________________________
Disposition or Penalty ____________________________________________________________________________________
C) Approximate Date ________________________
Arresting or Detaining Agency ___________________________________
Charge ________________________________________________________________________________________________
Disposition or Penalty ____________________________________________________________________________________
D) Approximate Date ________________________
Arresting or Detaining Agency ___________________________________
Charge ________________________________________________________________________________________________
Disposition or Penalty ____________________________________________________________________________________
36. Have you ever been placed on court probation as an adult?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
37. Were you ever required to appear before a juvenile court for an act which would have
been a crime if committed as an adult?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
38. Have you ever been a party in a non-work related civil lawsuit (e.g., small claims actions,
dissolutions, child custody, paternity, support, etc.) as either a plaintiff or defendant? . . . . . . . . . . . . . . . . . . . . . Yes No
39. Have the police ever been called to your home for any reason? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
40. Have you or your spouse/partner ever been referred to Child Protective Services? . . . . . . . . . . . . . . . . . . . . . . . Yes No
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