Financial Statement (Request For Ancillary Services)

REQUEST FOR ANCILLARY SERVICES Requests by retained attorneys for ancillary services at public expense, including appointment of investigators, experts, or others shall be presented for consideration and order by the Assistant Presiding Judge. Requests for ancillary services shall include the following: · Attorney's declaration (original and two copies) in support of the request that contains: · · · · · Summary of the charges and overview of the case If applicable, disclosure of attorney's representation of defendant in any other legal action Justification for appointment of investigator, expert, or service to be performed Requests for appointment of investigator must include an investigation plan containing outline of duties to be performed and relevance of duties to the case Attorney's estimate of the number of hours necessary to complete investigation · · · · A copy of the attorney/client retainer agreement A copy of the complaint, information, or indictment A completed financial statement of defendant If the defendant did not fund the retainer, a completed financial statement of any party (or parties) who funded the retainer For appointment of expert witness, the curriculum vitae of the expert Order for Appointment (original and two copies) · · · Order for appointment of investigator or order for appointment of experts must: · · Be directed to: San Luis Obispo Court Fiscal Services Contain full name, professional designation or professional license number of expert Contain court approved hourly and mileage (if applicable) rates, along with a cap amount · American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of San Luis Obispo San Luis Obispo Branch, County Government Center, 1050 Monterey Street, Room 220, San Luis Obispo, CA 93408 Grover Beach Branch, 214 South 16th Street, Grover Beach, CA 93433 Paso Robles Branch, 3DUN Street, Paso Robles, CA 93446 FOR COURT USE ONLY THE PEOPLE OF THE STATE OF CALIFORNIA Plaintiff, vs. Defendant, Case Number FINANCIAL STATEMENT Name: ____________________________________________________ Date of Birth: ____________________________ Address: __________________________________________________ City/Zip Code: ____________________________ Telephone # (Home): ________________________________________ Telephone # (Work): _______________________ Social Security #: ___________________________________________ Driver's License #: _________________________ Defendant's Occupation: _______________________________________________________________________________ Employer's Name: ___________________________________________Address: _________________________________ If Defendant is not currently working: Name of Last Employer: ____________________________________________Last Employment Date: _______________ Address of Employer: __________________________________________________________________________________ Marital Status: _____ Single _____ Married _____ Divorced _____ Separated Spouse's Name: ________________________________________________Date of Birth: ________________________ Spouse's Employer/Address: _____________________________________________________________________________ Spouse's Social Security #: _________________________________________Driver's License #: ____________________ Dependants: Name Address Relationship Age American LegalNet, Inc. www.FormsWorkFlow.com Monthly Financial Statement Monthly Income: Gross Salary (wages) Spouse's Gross Salary (wage) Unemployment/Disability Veterans Benefits Other Income (Itemize): $ Assets: Cash (Checking, Savings, Money Market Accts: Real Estate ­ Market Value Furniture and Fixtures Car(s) ­ Resale Value Personal Property (Boats, Cameras, etc.) IRA's Stocks, Bonds, etc. ­ Market Value $ TOTAL MONTHLY INCOME: Monthly Expenses: (include spouse) Mandatory Payroll Deductions: Voluntary Payroll Deductions: Rent or Mortgage Payment: Taxes and Assessments: Food: Clothing: Utilities (Gas, Electric, Water, Phone) Car Payment(s): Gasoline (Transportation Expense) Insurance Premiums: Child Support or Alimony: Contributions: Other expenses (itemize): TOTAL MONTHLY EXPENSES $ Other Assets (Itemize): $ TOTAL ASSETS: $ Liabilities: Balance Due on Real Estate: Balance Due on Personal Property: Attorney Fees Due: Other Creditors (itemize): $ $ TOTAL LIABILITIES: $ DECLARATION OF DEFENDANT I declare under penalty of perjury that the above is a true and correct statement of my financial status. This declaration is executed on _______________________________ , 20___ (date) at ____________________________ (city), California, County of __________________________________. __________________________________________ Signature of Defendant American LegalNet, Inc. www.FormsWorkFlow.com