Financial Disclosure Affidavit Form (Page 3 of 8) in pdf

Financial Disclosure Affidavit Form Page 3

Attachment 4

C. Do you claim an inability to earn income or receive benefits?

Yes (Go to D)

No (Go to Step 5)

D. If you claim an inability to earn income or receive benefits, you must provide documentary proof of this

inability.

I am attaching the following letter or other documentation from an institution (for example, a Correctional

Facility, Shelter, Hospital, other) to support my claim that I am unable to earn income or receive benefits.

________________________________________________________________________________________

(Go to Step 5)

Step 5: CASH AND ASSET INFORMATION

A. Cash

Do you currently have access to cash?

Yes. I have access to approximately $_________________ in cash.

No.

(Go to B)

B. Bank and Financial Accounts

1. Do you have banking and/or financial accounts?

Yes. (Go to 2)

No. (Go to C)

2. Do you have a checking account?

Yes. Attach a copy of the most recent statement for this account.

No.

(Go to 3)

3. Do you have a savings account, CD, or Money Market Account?

Yes. Attach a copy of the most recent statement for each account.

No.

(Go to C)

C. Inmate Commissary Account

Do you have an inmate commissary account?

Yes. I have attached a copy of the most recent statement for my commissary account.

No.

(Go to D)

Financial Disclosure Affidavit Form Page 3