Affidavit Concerning Financial Status - Leave To Appeal Granted By Supreme Court {CC 293}

Approved, SCAO Original - Circuit court 1st copy - Prosecutor 2nd copy - Defendant STATE OF MICHIGAN CIRCUIT COURT COUNTY Court address AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT CASE NO. COURT OF APPEALS: CIRCUIT COURT: Court telephone no. Defendant name, address, and telephone no. THE PEOPLE OF THE STATE OF MICHIGAN v The following is information concerning my present financial status. 1. RESIDENCE Rent 2. MARITAL STATUS Single Own Live with parents Room/Board Prison Number Married Divorced Separated Dependents: Number 3. INCOME a. Employer name and address b. Length of employment c. Average pay weekly Gross: $ monthly every two weeks Net: $ If no income, state NONE.) d. Other income (State monthly amount and source, such as DSS, VA, rent, pensions, spouse, unemployment, etc. 4. ASSETS (State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc. If no assets, state NONE. Attach an account statement and certification for assets in prisoner accounts.) 5. OBLIGATIONS (Itemize monthly rent, installment payments, mortgage payments, child support, etc.) Signature Subscribed and sworn to before me on Date , Signature: Notary public County, Michigan My commission expires: Date Notary public, State of Michigan, County of Administrative Order 2003-03 CC 293 (5/07) AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT American LegalNet, Inc. www.FormsWorkflow.com