Declaration of Financial Status

Complete all required fields and sign before submitting.

You do not qualify if your charge is an Infraction, example: 41-6a-601 Speeding

Personal Information

Full Name *

Phone *

Email *

Address *

Address Line 2

City *

State *

Zip *

Case Number *

Financial & Living Information

What kind of work do you do? *

How many hours per week do you work and what is your hourly rate? (If income is based on commission/tips, please list average income over the last year) *

What other sources of income do you have that you have not disclosed above? *

How many dependents under 18 do you support? *

How much do you pay in rent / mortgage a month? *

Do you own a car? *

YesNo

What other assets do you own (home, property, savings/checking accounts, etc)? *

How much do you pay each month in a cell phone bill? *

Describe any extraordinary expenses you may have *

Today's Date *

Acknowledgement and Signature

By typing my name below, I swear and affirm under penalties of contempt and perjury that the financial information given above is complete, accurate, and truthful.

Type Full Legal Name *

Typing your name acts as your electronic signature.