Santa Cruz — SUPCR-1127

Source: https://www.santacruz.courts.ca.gov/system/files/post-websupcr-1127-defendant-financial-eligibility-statement-appointment-counsel.pdf

SUPCR 1127 ATTORNEY OR PARTY WITHOUT AN ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY NAME: ADDRESS: CITY, STATE, ZIP:

TELEPHONE NO: FAX NO. (Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ 701 Ocean Street, Room 120 Santa Cruz, CA 95060 Santa Cruz Branch vs. DEFENDANT: DEFENDANT FINANCIAL ELIGIBILITY STATEMENT FOR APPOINTMENT OF CASE NUMBER: COUNSEL AND REIMBURSEMENT

1. Defendant Personal Information Street Address (include house and unit no.): City: State: Zip: Date of Birth: Phone Number: Marital Status: Spouse Name (if applicable): Number of Dependents:
2. Defendant Employment Information Are You Employed: Yes No (If No, is job pending Yes No) How Long Employed (Yrs/Mos): Name of Employer: Gross Pay Per Month: $ Spouse Gross Pay Per Month: $ Spouse’s Employer:
3. Defendant Other Income Information Do you receive income from sources other than employment? Yes No Source of income: Amount of monthly income: $
4. Defendant Financial Information Total Monthly Income (All Sources + Gross Pay): $ Total Monthly Expenses: $ Personal Savings and/or Assets: Yes No If Yes, How Much: $ Do You Own Real Estate or a Home: Yes No If Yes, what is the Value? $ Addresses of All Property: Please explain means of support if income is less than expenses:

Form Adopted for MANDATORY USE DEFENDANT FINANCIAL ELIGIBILTY Page 1 of 2 Superior Court of Santa Cruz County STATEMENT FOR APPOINTMENT OF Penal Code §987.8 SUPCR 1127 03/07/22 COUNSEL AND REIMBURSEMENT

PEOPLE OF THE STATE OF CALIFORNIA vs. CASE NUMBER: DEFENDANT:

5. Eligibility for Appointment of Counsel and Notice to Defendant: If an attorney is appointed to represent you and your case results in a felony or misdemeanor conviction, the Court may hold a hearing at the end of the criminal proceeding to determine your ability to pay all or a part of the cost associated with the legal assistance provided to you. You could be required to pay the costs of any appointed attorney in accordance with your ability to pay. The Court designates County Counsel as the “County Officer” to make an inquiry into your ability to pay before the hearing. Any court order to pay for legal fees will have the same force and effect as a judgment in a civil action and will be subject to execution.

   I declare under penalty of perjury that the foregoing is true and correct and that I understand the information described in paragraphs number five (5) and six (6), and that this declaration was executed on:

Date: at (County) , California.

Signature of Defendant

Form Adopted for MANDATORY USE DEFENDANT FINANCIAL ELIGIBILTY Page 2 of 2 Superior Court of Santa Cruz County STATEMENT FOR APPOINTMENT OF Penal Code §987.8 SUPCR 1127 03/07/22 COUNSEL AND REIMBURSEMENT