Save Print Clear

Municipal Courts of New Jersey

Financial Questionnaire to Establish Indigency

Part I - General Information

Application by Defendant
Parent or Guardian if Defendant is Under 18 or Incompetent

For: Indigent Defense Services*

Installment Payment of Fines/Penalties
*Note: if you are applying for indigent defense services, you may be charged with an application fee.

Are you receiving welfare or participating in another government based income maintenance program? Yes No

Are you only completing this form for installment payments of your fine? Yes No

Are you only charged with traffic or parking offenses? Yes No

If you answered "Yes" to all of the above 3 questions, go to Part VII and complete the Certification.

Complaint Number(s) Number of Co-Defendants

Charges

Last Name First Name Middle Initial Eye Color

Sex Date of Birth Social Security Number Driver's License Number State
Male Female
Home Address City State Zip

Home Phone Number How long at the above address? Marital Status
Married Single Separated Divorced Widowed
Number of those you support (children or other family members) Which income tax returns did you file last year?
Federal State None
Have you posted bail for this charge? If yes, name and address of bail bond agency or person who posted bail Amount Posted
Yes No $
Part II – Employment History
Are you now employed? Yes No If yes, length of employment? .

Current employer, if employed. If unemployed, last employer and date last employed.

Employer’s Address Phone Number Position Held

Part III – Income and Assets (include all assets you own by yourself or with someone else)
Gross Wages (before all deductions for taxes, etc.) $ . per Week 2 weeks Month

Other Income Received Monthly (for example: welfare, social security, unemployment compensation, $ .
worker's comp, disability pension)

Revised 11/2003, CN 10110 page 1 of 3

 Do you receive alimony or child support? By court order? Amount received monthly.
Yes No Yes No $
Does anyone contribute to the payment of your expenses? If yes, who? Total amount contributed monthly.
Yes No $
Monthly Income - All Sources
Monthly Income - All Sources
$
Checking Account: Bank Account Number Balance
$
Savings Account: Bank Account Number Balance
$
Other Cash Available Amount
$
Real Estate Owned? Address Current Value
Yes No Describe
$
Address Current Value

Describe
$
Vehicle/Vessel Year Make Model Current Value
Auto Truck Motorcycle Moped Boat $
Other Personal Property? Item Current Value
Yes No Describe
$
Total Assets
Total Assets
$ 0.00
Part IV – Expenses and Liabilities
Do you have a mortgage? Do you pay rent? Do you live in a halfway house? Monthly payment Balance owed
Yes No Yes No Yes No $ $
Do you have outstanding loan(s) (car, home, personal, etc.)? Total monthly payment Total balance owed
Yes No $ $
Do you owe insurance premiums and/or surcharges? Total monthly payment Total balance owed
Yes No $ $
Do you owe medical expenses – doctor/hospital/other? Total monthly payment Total balance owed
Yes No $ $
Do you owe credit card balances? Credit Limit Total monthly payment Total balance owed
Yes No $ $ $
Do you owe court fines/penalties/costs? Total monthly payment Total balance owed
Yes No $ $
Are you required to pay child support and/or alimony? Total monthly payment Total balance owed
Yes No $ $
Do you pay for living expenses (food, clothing, utilities, transportation, etc.?) Monthly Amount Living expenses owed
Yes No $ $

Revised 11/2003, CN 10110 page 2 of 3

 Do you owe money for attorney fees? Total monthly payment Total balance owed
Yes No $ $
Total monthly payment Total Liabilities
Total Liabilities
$ 0.00 $ 0.00
Total Assets Total Liabilities Total Net Worth
Total Net Worth
$ 0.00 - $ 0.00 = $ 0.00
Part V – Attorney Information
Can you afford to pay for an attorney? Yes No If yes, how much? .

Can parents, guardians, relatives or friends help you pay for an attorney? Yes No

Did a private attorney ever represent you Yes No

Name of Attorney Address Phone number

Who paid for attorney? Amount Paid

$
Part VI– Authorization
I authorize the court or the Administrative Office of the Courts to conduct such investigation as may be necessary to
verify my financial status, which may include but may not be limited to a review of my credit history, state and/or federal
income tax returns, wage records, bank accounts and other financial institution records.

Signature Date

Witness, Name and Position Date

Part VII– Certification Pursuant to New Jersey Court Rule 1:4-4(b)

I certify that the foregoing statements made by me are true. I am aware and understand that if any of the foregoing
statements made by me are willfully false, i am subject to punishment.

Signature Date

For Court Use Only

Counsel Assigned Application Fee
Yes No Assessed $ . Waived Partial Payment Schedule .
Counsel Denied - Reasons

Approved by Judge
Yes No
Signature Date
Notes

The courthouse is accessible to those with disabilities. Please notify the court if you will require assistance.

Revised 11/2003, CN 10110 page 3 of 3