2. Have you received within the past twelve months any money from any of the following sources?
a. Business, profession or form of self-employment?
Yes ____ No ____
b. Rent payments, interest or dividends?
Yes ____ No ____
c. Pensions, annuities or life insurance payments?
Yes ____ No ____
d. Gifts or inheritances?
Yes ____ No ____
e. Any other sources?
Yes ____ No ____
If the answer to any of the above is “yes,” describe each source of money and state the
amount received from each during the past twelve months.
3. Do you own any cash, or do you have money in a checking or savings account? (Include any
funds in prison accounts.)
Yes ____ No ____
If the answer is “yes,” state the total value of the items owned.
4. Do you own real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding
ordinary household furnishings and clothing)?
Yes ____ No ____
If the answer is “yes,” describe the property and state its approximate value.
5. List the persons who are dependent upon you for support, state your relationship to those
persons, and indicate how much you contribute toward their support.
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