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Financial Declaration - Maine
| Financial Declaration Form. This is a Maine form and can be used in District Court Federal . |
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UNITE D STAT ES DISTRICT COURT DISTRI CT OF MAINE FINANCIAL DECLARATION CASE # AND NAME: NAM E: P HONE #: ADDRES S: MARITAL STAT US: Single Married Divorced NUMBER OF DEPENDENTS : WARNI NG: The information you provide in order to obtain court-appointed representation is subject to the following limitations: (1) The attorney/client privilege may not apply; (2) The information is subject to being filed with the Court for future examination by the United States Attorney; (3) A false or dishonest answer could be punished as a crime; and (4) The form must be signed under penalty of perjury. ASSETS I. INCOME PRES ENT EMPLOYERS NAM E: A DDR ESS : MONTHLY WAGES: Gross Net IF NOT CURRE NTL Y EMPLOYED : NAME YOUR PRIOR EMPLOYER: MONTH and YEAR L AST EMP L OYMENT: MONTHLY EARNINGS LAST EM PLOYMENT: OTHER INCOME: WEL FAR E: SOCIAL SECURIT Y: PENSION: OTHER: II. PROPERTY REAL ES TATE VAL UE MORTGAGE AMOUNT NET EQUITY 1. HOME 2. OTHER VEHICLE S VAL UE OWED NET 1. 2. III. OTHER ASSETS 1. CASH ON HAND 5. J EWEL R Y 2. BANK ACCOUNTS 6. STOCK S 3. CRE DIT UNION 7. BONDS 4. ACCOUNTS RECEIVABL E 8. OTHER USDCME (Rev. 12/00) Previous editions obsolete. (COMPLETE REVERSE SIDE) <<<<<<<<<********>>>>>>>>>>>>> 2 LIABILITIES I. REAL ES TATE LENDER TOTAL OWED MONTHLY PAYM ENTS 1. 2. II. MOTOR VEHICLES LENDER TOTAL OWED MONTHLY PAYM ENTS 1. 2. III. GENERAL DEBTS LENDER TOTAL OWED MONTHLY PAYM ENTS 1. 2. 3. 4. IV. MONTHLY HOUSEHOLD EXPENSES 1. R ENT 7. TRANSPORTATI ON 2. UTIL ITIES 8. CL OTHES 3. TELEP HONE 9. MEDICAL/DENTAL 4. GR OCER IE S 10. INS UR ANCE 5. CHILD SUPPORT 11. TAXES 6. AL IMONY 12. OTHER I DECL ARE UNDER PENALT Y OF PERJURY THAT THE FO REGOING INFORMATION IS TRUE AND CORRE CT TO THE BEST OF MY KNOWLEDGE AND BELI EF. DATE SIGNATURE REQUES T APPROVED: REQUES T DISAPPROVED : Date: United States Magistrate Judge U nited S tates District J udge
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