Defendant'S Financial Statement And Notice To Defendant Page 2
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1
2MC-210
CASE NUMBER:
PEOPLE OF THE STATE OF CALIFORNIA v.
DEFENDANT:
OTHER MONTHLY INCOME
9.
Defendant
Spouse
a.
Unemployment and disability
..............
$
$
a.
Unemployment and disability
..............
Social Security
.....................................
$
$
b.
Social Security
.....................................
b.
c.
Welfare, TANF
...................................
$
c.
$
Welfare, TANF
...................................
Veteran's benefits .................................
$
$
d.
Veteran's benefits .................................
d.
e.
Worker's compensation
......................
$
$
e.
Worker's compensation
......................
$
Child support payments .........................
$
f.
Child support payments .........................
f.
Spousal support payments ...................
$
$
g.
g.
Spousal support payments ...................
h.
All other income not elsewhere listed ...
$
$
h.
All other income not elsewhere listed ...
Total: $
Total: $
EXPENSES
10.
Monthly expenses being paid by defendant alone or by defendant and spouse
a.
Rent or house payments .......................
$
f.
Clothing and laundry
............................
$
b.
Car payments
.....................................
$
g.
Food .....................................................
$
c.
Transportation payments .....................
$
h.
Support payments ................................
$
d.
Medical and dental payments ..............
$
i.
Insurance payments
.............................
$
e.
Loan payments ....................................
$
j.
Other payments (union, taxes, utilities) ...
$
Total (a-j): $
11.
Installment payments other than those listed in item 10.
Name of Creditor
MonthIy Payment
Balance Owed
$
$
a.
$
$
b.
$
$
c.
$
$
d.
$
$
e.
Total: $
Total: $
ASSETS
12.
What do you own? (State value):
Cash
...............................................................................................................
$
a.
b.
House equity
.................................................................................................
$
c.
Cars, other vehicles and boat equity
.............................................................
$
(List make, year, and license number of each)
d.
Checking, savings, and credit union accounts
.................................................
$
(List name and account number of each)
e.
Other real estate equity
................................................................................
$
f.
Income tax refunds due
.................................................................................
$
g.
Life insurance policies (ordinary life, face value)
..........................................
Length of ownership
$
h.
$
Other personal property (jewelry, furniture, furs, stocks and bonds, etc.) ......
Total: $
13.
ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO DEFENDANT: If an attorney is appointed to represent you, the court will,
at the conclusion of the criminal proceedings, after a hearing, make a determination of your ability to pay all or a portion of the cost of the attorney.
If the court determines that you are at that time able to pay, the court will order you to pay all or part of such cost. Such an order will have the
same force and effect as a judgment in a civil action and will be subject to execution.
Declaration of Defendant
I declare under penalty of perjury that the foregoing is true and correct, and that I understand the notice contained in item 13, under
the laws of the state of California.
Date:
(Signature of Defendant)
MC-210 [Rev. January 1, 2009]
Page 2 of 2
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
APPOINTMENT OF COUNSEL AND REIMBURSEMENT
AND RECORD ON APPEAL AT PUBLIC EXPENSE
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