San Mateo — Declaration to Obtain Services of Court Appointed Counsel

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/cr-2a_declarationobtain_court_appointed_counsel.pdf

Answer every question Please print all answers DECLARATION UNDER PENALTY OF PERJURY TO OBTAIN SERVICES OF COURT-APPOINTED COUNSEL

CASE NUMBER: ________________________________

NAME: ______________________________________________ DATE OF BIRTH: //______ PLACE OF BIRTH: _______________________ LAST, FIRST MIDDLE MO. DAY YEAR STATE OR NATION

ADDRESS: ____________________________________________________________________________________________________________________ NUMBER STREET CITY STATE

SOCIAL SECURITY NO: _____________________________ E-MAIL ADDRESS: _________________________________________________

TELEPHONE NUMBER(S): ( )____________________ ( )____________________ ( )____________________ RESIDENCE EMPLOYMENT CELL

1. Are you employed: yes no (see #2 & 3 below) If YES, Employed by employer Self-employed Name and address of Employer: ________________________________________________________________________________________________

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2. Do you expect to start working soon? yes no.

3. If you are unemployed, how have you supported yourself while not working? : ____________________________________________________________

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4. Do you receive any money from any other source ? yes no. If yes please check source: welfare pension unemployment disability alimony spousal support Other, please state:______________________________________
5. Does your spouse have a job? yes no
6. Does your spouse receive any money from any other source? yes no If yes, please state: __________________________
7. Do you own, or are you renting your home? yes no
8. Do you have a checking account? yes no. Do you have a savings account yes no
9. Does your spouse have a checking account? yes no; Savings account? yes no
10. Do you or your wife/husband own stock or bonds? yes no; Jewelry? yes no
11. Do you or your spouse own: Automobiles? yes no. Trucks? yes no. Trailers? yes no. Boat? yes no.
12. Number of Dependents: ___________ ASSETS / INCOME: EXPENSES: Your total monthly salary ..................................... $ ___________ Rent payment per month .................................... $ ___________ Spouse's total monthly salary .............................. $ ___________ Mortgage payment per month ............................. $ ___________ Other income per month ...................................... $ ___________ Food ................................................................... $ ___________ Amount of money in your possession now ........... $ ___________ Utilities (gas, electric, phone, garbage) ............... $ ___________ Amount of money at home ................................... $ ___________ Insurance ............................................................ $ ___________ Amount of money owed to you ............................. $ ___________ Credit Payments ................................................. $ ___________ Amount of money due for tax refund .................... $ ___________ Child care payments ........................................... $ ___________ Amount of money in savings account ................... $ ___________ Clothing .............................................................. $ ___________ Amount of money in spouse's savings account .... $ ___________ Medical/Dental .................................................... $ ___________ Cash value of insurance ....................................... $ ___________ Spousal support/alimony ..................................... $ ___________ Cash value of spouse's insurance ........................ $ ___________ Transportation .................................................... $ ___________ Cash value of autos ............................................. $ ___________ Other (please specify .......................................... $ ___________ Cash value of trucks............................................. $ ___________ _______________________________________ $ ___________ Cash value of trailers ........................................... $ ___________ _______________________________________ $ ___________ Cash value of boats ............................................. $ ___________ _______________________________________ $ ___________ Equity in real estate ............................................. $ ___________ _______________________________________ $ ___________ TOTAL ASSETS/INCOME ................................... $ ___________ TOTAL EXPENSES ........................................... $ ___________

I make the above statements and representations under penalty of perjury and with the purpose of having the Court appoint counsel for me at County expense.

DATED:

Signature

Form adopted for Mandatory Use Local Court Form CRC -2 Rev September 2022 Pen.Code § 987.5, 987.8, 987.81