Fillable Defendants Financial Statement Request For Appt Of Counsel (Clerk of the Superior Court)

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Defendants Financial Statement Request For Appt Of Counsel (Clerk of the Superior Court)

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U.S.A. forms for Clerk of the Superior Court

BROWSE CLERK OF THE SUPERIOR COURT (AZ) FORMS

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Form 5(a) 1 of 3
Arizona Superior Court, Pinal County, Arizona
INSTRUCTIONS TO THE DEFENDANT: You are to answer the following questions so the Judge can decide
whether to appoint an attorney to represent you and/or, if a bond is required, how much it should be, or any
other matter relating to indigence. Use care in filling in your answers. If you need more space for any answer,
note such and write on the back of the page. If you knowingly give false or misleading information, you may be
punished for contempt of court or subjected to prosecution for fraud or perjury.
1. Full name:
2. Check the appropriate box: [ ] Single [ ] Married, living w/ spouse [ ] Married but separated [ ] Divorced
[ ] Widowed [ ] Partnered
3. In addition to yourself, how many other adults do you support? How many children?
INCOME:
4. List below in Column 1 the money that you are paid or receive each month. If you are married and are living
with your spouse, list below in Column 2 the money that your spouse is paid or receives each month. If you
are separated, divorced, widowed, partnered or single, leave Column 2 blank.
Column 1 Column 2
Amount paid to Me Monthly Amount paid to Spouse Monthly
a. Wages, Salaries, Self
Employment Income $ $
b. Payroll deductions $ $
c. Unemployment compensation $ $
d. Welfare benefits $ $
e. Disability benefits $ $
f. Veteran’s benefits $ $
g. Social Security benefits $ $
h. Worker’s compensation $ $
i. Accident benefits $ $
j. Retirement benefits $ $
k. Allotment checks $ $
l. Interest $ $
m. Dividends $ $
n. Child support received $ $
o. Alimony or maintenance received $ $
p. Total of any other income received $ $
Source:
TOTAL MONTHLY INCOME: $ $
ASSETS:
5. Cash: List below the amounts of cash held or value of:
a. Cash on you, your spouse, or in your jail property, and at home $
b. Cash in banks, credit unions, and elsewhere $
c. Cash owed to you or to your spouse by others $
d. Stocks and bonds; insurance policy cash values $
[CASE/COMPLAINT NO.]
DEFENDANT’S
FINANCIAL
STATEMENT
(Confidential)
STATE OF ARIZONA Plaintiff
-vs-
Defendant (FIRST, MI, LAST)
Reset Form
Form 5(a) 2 of 3
e. Beneficial interest in a trust $
6. Personal Property: List below any valuable personal property you own and have not listed above which is
not needed by you or your family for day-to-day living.
a. Description $ $ $
(value) (owed) (net value)
b. Description $ $ $
(value) (owed) (net value)
c. Description $ $ $
(value) (owed) (net value)
7. Auto: Complete the following information about any motor vehicles (e.g.: cars, trucks, trailers, boats,
airplanes, motorcycles) that you are buying, that you own, or in which you claim to have an interest.
a. Make, Year and Model $ $ $
(value) (owed) (net value)
b. Make, Year and Model $ $ $
(value) (owed) (net value)
8. Real Estate: Complete the following information about any real property (your home, other land, or
buildings) that you are buying, that you own, or in which you claim to have an interest.
a. Location $ $ $
(value) (owed) (net value)
b. Location $ $ $
(value) (owed) (net value)
TOTAL AVAILABLE ASSETS:
$
EXPENSES:
9. List below all monthly expenses not already deducted from your pay.
a. Rent or house payment $
b. Total cost of utilities (water, electric, gas, telephone, trash) $
c. Food $
d. Credit card payments $
e. Installment loan payments $
f. Charge account payments $
g. Motor vehicle payments $
h. Union dues $
i. Medical care costs (doctors, dentists, medicine) $
j. Child support and alimony $
k. Cost of baby-sitter $
l. Motor vehicle insurance, maintenance and gas $
10. Do you have any expenses (monthly or otherwise) not shown above? If yes, please list below.
a. $
(how often paid) (how much)
b. $
(how often paid) (how much)
c. $
(how often paid) (how much)
TOTAL MONTHLY EXPENSES: $
Form 5(a) 3 of 3
11. Are any of your expenses past due? If yes, please list below.
a. $
(how often paid) (how much)
b. $
(how often paid) (how much)
c. $
(how often paid) (how much)
12. Do you have an attorney to help you with this case? [ ] Yes [ ] No
If yes, what is his/her name: If no, are you planning to hire your own
attorney? [ ] Yes [ ] No
13. Do you want the Court to appoint an attorney (public defender) to help you with this case? [ ] Yes [ ] No
a. How much can you pay as a down payment for attorney fees? $
b. How much can you pay each month for attorney fees? $
14. Oath under penalty of perjury: I have truthfully and completely given the information in this statement. I
have not knowingly concealed, or in any way misrepresented, my financial resources. I am aware that I
may be held in contempt of court, or prosecuted for perjury if I have made any false statements or
misrepresentation, or concealment, or if I continue to accept the services of a court appointed attorney after
my financial condition has materially changed without notifying my court appointed attorney. In any such
case, I understand that this application may be used against me.
I hereby make these representations under PENALTY OF PERJURY:
Date: Defendant Signature:
Witnessed by: Social Security No.:
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Defendants Financial Statement Request For Appt Of Counsel (Clerk of the Superior Court)

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Completed 25 July 2020

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