Defendant'S Financial Statement And Notice To Defendant
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1
2MC-210
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
To keep other people from
STREET ADDRESS:
seeing what you entered on
MAILING ADDRESS:
your form, please press the
CITY AND ZIP CODE:
Clear This Form button at the
BRANCH NAME:
PEOPLE OF THE STATE OF CALIFORNIA v.
end of the form when finished.
DEFENDANT:
DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT
(check all that apply)
ELIGIBILITY FOR APPOINTMENT OF COUNSEL
REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL
CASE NUMBER:
ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE
d.
1. a.
Defendant's name:
Date of birth:
b.
Other names used:
Telephone number:
e.
f.
Driver's license number:
c.
Address:
2.
Defendant's present employment:
a.
Occupation:
b.
Name of employer:
c.
Address:
Gross pay per month: $
week: $
day: $
d.
e.
Take-home pay per month: $
week: $
day: $
Name of union:
f.
Name of credit union:
g.
3.
If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was employed.
a.
Name:
b.
Address:
c.
Last date of employment:
Defendant
is
is not
married.
4.
5.
a.
d.
Spouse's name:
Date of birth:
b.
e.
Telephone number:
Other names used:
f.
Driver's license number:
c.
Address:
6.
Spouse's present employment
a.
Occupation:
b.
Name of employer:
c.
Address:
d.
Gross pay per month: $
week: $
day: $
Take-home pay per month: $
week: $
day: $
e.
Name of union:
f.
Name of credit union:
g.
7.
If spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed.
a.
Name:
b.
Address:
c.
Last date of employment:
8.
Dependents
Name
Address
Relationship
Aqe
Page 1 of 2
Form Approved for Optional Use
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
Pen. Code, § 987. 8
Judicial Council of California
APPOINTMENT OF COUNSEL AND REIMBURSEMENT
MC-210 [Rev. January 1, 2009]
AND RECORD ON APPEAL AT PUBLIC EXPENSE
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