Santa Clara — CR-6089*

Source: https://santaclara.courts.ca.gov/system/files/forms/cr-6089.pdf

ATTACHMENT CR-6089 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA FOR COURT USE ONLY STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

PEOPLE OF THE STATE OF CALIFORNIA vs.

DEFENDANT:

CASE NUMBER:

DEFENDANT’S FINANCIAL STATEMENT IN SUPPORT OF ANCILLARY FEES REQUEST

(Attach additional sheets if the space provided below for any item is not sufficient.)

PERSONAL INFORMATION

1. Name: EMPLOYMENT

2. What are your sources of income and occupation? (Provide job title and name of employer))

3. If not employed, describe all sources of income (specify):

4. How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify):

5. What is your gross pay each pay period? $

6. What is your take-home pay each pay period? $

7. If your spouse earns any income, give the name of your spouse, the name and address of the business or employer, job title, and division or office (specify):

8. Other sources of income (specify):

CASH, BANK DEPOSITS 9. How much money do you have in cash? $ 10. How much other money do have in bank, saving and loans, credit unions, and other financial institutions either in your own name or jointly (list):

Name and address of financial institution Account number Individual or joint? Balance
a. $
b. $
c. $

PROPERTY 11. List all automobiles, other vehicles, and boats owned in your name or jointly: Legal Owner if different Make and Year Value from registered owner Amount owed a. $ $ b. $ $ c. $ $ 12. List all real estate owned in your name or jointly: Address of real estate Fair market value Amount owed a. $ $ b. $ $

CR-6089 REV 11/05/15 DEFENDANT’S FINANCIAL STATEMENT IN SUPPORT Page 1 of 2 OF ANCILLARY FEES REQUEST

ATTACHMENT CR-6089 PEOPLE OF THE STATE OF CALIFORNIA VS. CASE NUMBER:

DEFENDANT:

OTHER PERSONAL PROPERTY (Do not list household furniture and furnishings, appliances, or clothing.) 13. List anything of value not listed above owned in your name or jointly (continue on attached sheet if necessary): Description Value Address where property is located a. $ b. $ c. $ ASSETS 14. List all other assets, including stocks, bonds, mutual funds and other securities (specify):

15. Is anyone holding assets for you? Yes No If yes, describe the assets and give the name and address of the person on entity holding each asset (specify):

16. Except for attorney fees in this matter and ordinary and routine household expenses, have you disposed of or transferred any assets since your arrest on this matter? Yes No If yes, give the name and address of each person or entity who received any asset and describe each asset (specify):

DEBTS 17. Loans (give details):

18. Taxes (give details):

19. Support arrearages (attach copies of orders and statements):

20. Credit cards (give creditor’s name and address and the account number):

21. Other debts (specify):

22. Monthly living expenses (other than what is listed above): a. Housing costs: $ b. Utilities: $ c. Food: $ d. Other: $

23. Any other information you want the Court to consider or that the Court has requested you provide.

I declare under penalty of perjury under the laws of the State of California that the information contained in this form is true and correct.

Date:

SIGN

(TYPE OR PRINT NAME) (SIGNATURE)

I, (name) , a certified interpreter, having been duly sworn, truly translated this form to the defendant in the (specify language): language. The defendant indicated that he/she understood the contents of the form and he/she completed the form. Date:

SIGN

(TYPE OR PRINT NAME) (SIGNATURE) Reset Form

CR-6089 REV 11/05/15 DEFENDANT’S FINANCIAL STATEMENT IN SUPPORT Page 2 of 2 OF ANCILLARY FEES REQUEST