Financial Resources Assessment Form

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Name ________________________________
Dkt. No. _________________
Date _______________
FINANCIAL RESOURCES ASSESSMENT FORM
ASSETS
LIABILITIES
Item
Fair Market Value
Item
Balance
Cash on Hand
_____________
Mortgage on Residence
__________________
Checking Account(s)
_____________
Other Mortgage(s)
__________________
Savings Account(s)
_____________
Loan(s) Outstanding
__________________
Securities (stocks, bonds, _____________
(personal, auto, etc.)
__________________
mutual funds)
_____________
Credit Account(s)
__________________
Other Investments
_____________
Charge Card(s)
__________________
(limited partnerships
__________________
nd
2
trust deeds)
Past Due Debts
__________________
Debts or Loans owed you _____________
Medical/Dental
__________________
Cash or Other Assets
Attorney Fees
__________________
held for you by others
_____________
Child/Spousal Support
__________________
Life Insurance Cash Value_____________
Total Liabilities
$_________________
IRA/Keough Plan
_____________
Please attach verification
Residence
_____________
Other Real Estate
_____________
EXPENDITURES
Auto #1
_____________
Item
Monthly
Auto #2
_____________
Other Vehicles (boat
_____________
Rent/Mortgage
__________________
plane, motorcycle)
_____________
Other Mortgage(s)
__________________
Other Assets (itemize)
_____________
Property Taxes
__________________
_____________
Insurance (life, auto, home,
__________________
_____________
health)
__________________
Loan Payments
__________________
Total Assets
$____________
Credit Account(s)
__________________
Charge Card(s)
__________________
INCOME
Medical/Dental
__________________
Attorney’s Fees
__________________
Item
Monthly Income
Child/Spousal Support
__________________
Food
__________________
Your Wage/Salary (net)
_____________
Transportation
__________________
Spouse’s Wage/Salary (net)____________
Utilities
__________________
Child/Spousal Support
_____________
Clothing
__________________
Interest/Dividends
_____________
Rent/Royalties
_____________
Total Expenditures
$_________________
Other Income (itemize)
_____________
Please attach verification
_____________
Do you have insurance?
__________________
Total Income
$____________
Name of Carrier/Policy Number
__________________
NET WORTH
$____________
Are you covered by another’s
__________________
insurance?
__________________
Name of Carrier/Policy Number
__________________
Do you receive public assistance? __________________
(AFDC, SSI, Disability) If yes,
__________________
Please list agency & caseworker:
__________________
Phone number:
__________________
Defendant’s signature_______________________
Date: __________
Based on the above information, I recommend that the defendant pay $_______________.
Officer Signature________________________
Approved by: __________________________________

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