Financial Declaration
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1
2UNITED STATES DISTRICT COURT
DISTRICT OF NEW HAMPSHIRE
FINANCIAL DECLARATION
CASE # AND NAME: ______________________________________________________________________________
NAME:
__________________________________________
PHONE #: ____________________________
ADDRESS:
__________________________________________
MARRIED:
YES [ ]
NO [ ]
__________________________________________
NUMBER OF DEPENDENTS: ___________
WARNING:
The information you provide in order to obtain court-appointed representation is subject to the following
limitations:
(1)
The attorney/client privilege may not apply;
(2)
The information is subject to being filed with the Court for future examination by the United States
Attorney;
(3)
A false or dishonest answer could be punished as a crime; and
(4)
The form must be signed under penalty of perjury.
ASSETS
I. INCOME
EMPLOYER'S NAME: ______________________________________________________________
MONTHLY WAGES: Gross ___________________ Net ___________________________
WELFARE: ________________ SOCIAL SECURITY (Amount Rec’d): _______________
PENSION: _________________ OTHER: ________________________________________
SPOUSE'S EMPLOYER:_____________________________________________________________
MONTHLY WAGES: Gross ___________________ Net ___________________________
WELFARE: ________________ SOCIAL SECURITY (Amount Rec’d): _______________
PENSION: _________________ OTHER: ________________________________________
II. PROPERTY
REAL ESTATE
VALUE
MORTGAGE
NET
1. HOME
_________________
_________________
_________________
2. OTHER
_________________
_________________
_________________
3. OTHER
_________________
_________________
_________________
VEHICLES
VALUE
OWED
NET
1. _________________
_________________
_________________
_________________
2. _________________
_________________
_________________
_________________
3. _________________
_________________
_________________
_________________
III. OTHER ASSETS
1. CASH ON HAND
___________________ 6. JEWELRY _____________________
2. CHECKING ACCOUNT
___________________ 7. STOCKS
_____________________
3. SAVINGS ACCOUNT
___________________ 8. BONDS
_____________________
4. CREDIT UNION
___________________ 9. OTHER
_____________________
5. ACCOUNTS RECEIVABLE ___________________
(COMPLETE REVERSE SIDE)
USDCNH-15 (Rev 11-04) (Previous editions obsolete)
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