Mariposa — Financial Declaration - COL-001

Source: https://www.mariposa.courts.ca.gov/files/COL-001-%20Financial%20Declaration.pdf

CONFIDENTIAL MARIPOSA COUNTY SUPERIOR COURT FINANCIAL DECLARATION

Case No. COURT USE ONLY Name Date of Birth / / Street/P.O. Box Social Security No. / / City, State, Zip Phone No. (home) ( ) Occupation Phone No. (work)

Number in Family

Employer (Name and Address)

HOUSEHOLD INCOME EXPENSES ASSETS
(GROSS PER MONTH)

1. Earnings/Wages 1. Rent 1. Cash in hand
2. Pension& retirement 2. Utilities 2. Cash in checking
3. Social Security/SSI 3. Insurance Account No.
4. Unemployment 4. Food Name/Location
5. Disability 5. Clothing 3. Cash in Savings
6. Welfare/AFDC 6. Other Account No.
7. Food Stamps Name/Location
8. Child/Spousal Support 4. Credit/Card
9. Dividends/Interest Account No.
10. Rental Income Name/ Location
11. All Other Income 5. Real Estate Description 6. Personal Property Boat Automobile

TOTAL MONTHLY INCOME TOTAL MONTHLY EXPENSES TOTAL ASSESTS

I understand and agree that my financial status may be subject to review in connection with a consumer credit report. I certify under penalty of perjury that the foregoing is true and correct.

(Date) (Signature)

Local Form for Optional Use Mariposa Superior Court COL-001 [New November 2012]