Fillable Municipal Courts of New Jersey Financial Questionnaire to (City of Stafford)

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Municipal Courts of New Jersey Financial Questionnaire to (City of Stafford)

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U.S.A. forms for City of Stafford

BROWSE CITY OF STAFFORD (NJ) FORMS

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Revised 11/2003, CN 10110 page 1 of 3
Municipal Courts of New Jersey
Financial Questionnaire to Establish Indigency
Part I - General Information
Application by
Defendant
Parent or Guardian if Defendant is Under 18 or Incompetent
For:
Indigent Defense Services*
Installment Payment of Fines/Penalties
*Note: if you are applying for indigent defense services, you may be charged with an application fee.
Are you receiving welfare or participating in another government based income maintenance program? Yes No
Are you only completing this form for installment payments of your fine? Yes No
Are you only charged with traffic or parking offenses? Yes No
If you answered "Yes" to all of the above 3 questions, go to Part VII and complete the Certification.
Complaint Number(s)
Number of Co-Defendants
Charges
First Name
Middle Initial
Eye Color
Sex
Date of Birth
Social Security Number
Driver's License Number
State
Male Female
Home Address
City
State
Zip
Home Phone Number
How long at the above address?
Marital Status
Married Single Separated Divorced Widowed
Number of those you support (children or other family members)
Which income tax returns did you file last year?
Federal State None
Have you posted bail for this charge?
If yes, name and address of bail bond agency or person who posted bail
Amount Posted
Yes No
$
Part II – Employment History
Are you now employed? Yes No If yes, length of employment? .
Current employer, if employed. If unemployed, last employer and date last employed.
Employer’s Address
Phone Number
Position Held
Part III – Income and Assets (include all assets you own by yourself or with someone else)
Gross Wages (before all deductions for taxes, etc.)
$
.
per Week 2 weeks Month
Other Income Received Monthly (for example: welfare, social security, unemployment compensation,
worker's comp, disability pension)
$
.
Save
Print
Clear
Revised 11/2003, CN 10110 page 2 of 3
Do you receive alimony or child support?
By court order?
Amount received monthly.
Yes No Yes No
$
Does anyone contribute to the payment of your expenses?
If yes, who?
Total amount contributed monthly.
Yes No
$
Monthly Income - All Sources
Monthly Income - All Sources
$
Checking Account: Bank
Account Number
Balance
$
Savings Account: Bank
Account Number
Balance
$
Other Cash Available
Amount
$
Real Estate Owned?
Address
Current Value
Yes No
Describe
$
Address
Current Value
Describe
$
Vehicle/Vessel
Year
Make
Model
Current Value
Auto Truck Motorcycle Moped Boat
$
Other Personal Property?
Item
Current Value
Yes No
Describe
$
Total Assets
Total Assets
$
Part IV – Expenses and Liabilities
Do you have a mortgage?
Do you pay rent?
Do you live in a halfway house?
Monthly payment
Balance owed
Yes No Yes No Yes No
$ $
Do you have outstanding loan(s) (car, home, personal, etc.)?
Total monthly payment
Total balance owed
Yes No
$ $
Do you owe insurance premiums and/or surcharges?
Total monthly payment
Total balance owed
Yes No
$ $
Do you owe medical expenses – doctor/hospital/other?
Total monthly payment
Total balance owed
Yes No
$ $
Do you owe credit card balances?
Credit Limit
Total monthly payment
Total balance owed
Yes No
$
$ $
Do you owe court fines/penalties/costs?
Total monthly payment
Total balance owed
Yes No
$ $
Are you required to pay child support and/or alimony?
Total monthly payment
Total balance owed
Yes No
$ $
Do you pay for living expenses (food, clothing, utilities, transportation, etc.?)
Monthly Amount
Living expenses owed
Yes No
$ $
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Revised 11/2003, CN 10110 page 3 of 3
Do you owe money for attorney fees?
Total monthly payment
Total balance owed
Yes No
$ $
Total Liabilities
Total monthly payment
Total Liabilities
$ $
Total Net Worth
Total Assets
Total Liabilities
Total Net Worth
$
-
$
=
$
Part V – Attorney Information
Can you afford to pay for an attorney? Yes No If yes, how much? .
Can parents, guardians, relatives or friends help you pay for an attorney? Yes No
Did a private attorney ever represent you Yes No
Name of Attorney
Address
Phone number
Who paid for attorney?
Amount Paid
$
Part VI– Authorization
I authorize the court or the Administrative Office of the Courts to conduct such investigation as may be necessary to
verify my financial status, which may include but may not be limited to a review of my credit history, state and/or federal
income tax returns, wage records, bank accounts and other financial institution records.
Signature
Date
Witness, Name and Position
Date
Part VII– Certification Pursuant to New Jersey Court Rule 1:4-4(b)
I certify that the foregoing statements made by me are true. I am aware and understand that if any of the foregoing
statements made by me are willfully false, i am subject to punishment.
Signature
Date
For Court Use Only
Counsel Assigned
Application Fee
Yes No Assessed $ .
Waived Partial Payment Schedule .
Counsel Denied - Reasons
Approved by Judge
Yes No
Signature
Date
Notes
The courthouse is accessible to those with disabilities. Please notify the court if you will require assistance.
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Municipal Courts of New Jersey Financial Questionnaire to (City of Stafford)

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Completed 16 July 2020

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