Form Dpca-500iid-Fdr - Ignition Interlock Device Program - Financial Disclosure Report Page 5

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NEW YORK STATE
IGNITION INTERLOCK DEVICE PROGRAM - FINANCIAL DISCLOSURE REPORT
CONFIDENTIAL
F: MONTHLY EXPENSES CONTINUED *
SPECIFY BELOW:
AMOUNTS
$
CREDIT CARD CHARGE(S)/OTHER
LOAN AMOUNT(S)
$
$
$
$
WORK RELATED TRAVEL
$
RECREATION
$
$
$
OTHER EXPENSES
$
$
$
* ATTACH ADDITIONAL SHEET WITH REQUIRED INFORMATION IF MORE SPACE IS NECESSARY.
THE INFORMATION PRESENTED HEREIN IS TRUTHFUL AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
DEFENDANT SIGNATURE
DATE
PRINT NAME
DPCA-500IID-FDR Available at
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