CR-115
NAME OF VICTIM ON WHOSE BEHALF RESTITUTION IS ORDERED: FOR COURT USE ONLY
NAME OF COURT:
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PEOPLE OF THE STATE OF CALIFORNIA
vs.
DEFENDANT:
CASE NUMBER:
DEFENDANT'S STATEMENT OF ASSETS
It is a misdemeanor to make any willful misstatement of material fact in completing this form. (Pen. Code, § 1202.4(f)(4).)
(Attach additional sheets if the space provided below for any item is not sufficient.)
PERSONAL INFORMATION
1. a. Name: f. Driver license number:
b. AKA: State of issuance:
c. Date of birth: g. Home address (incl. city/zip):
d. Social security number: h. Home telephone no.:
e. Marital status: i. Employer's telephone no.:
EMPLOYMENT
2. What are your sources of income and occupation? (Provide job title and name of division or office in which you work.)
3. a. Name and address of your business or employer (include address of your payroll or human resources department, if different):
b. If not employed, names and addresses of all sources of income (specify):
4. How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify):
5. What is your gross pay each pay period? $
6. What is your take-home pay each pay period? $
7. If your spouse earns any income, give the name of your spouse, the name and address of the business or employer, job title, and
division or office (specify):
8. Other sources of income (specify):
CASH, BANK DEPOSITS
9. How much money do you have in cash? $
10. How much other money do you have in banks, savings and loans, credit unions, and other financial institutions either in your own
name or jointly (list):
Name and address of financial institution Account number Individual or joint? Balance
a. $
b. $
c. $
PROPERTY
11. List all automobiles, other vehicles, and boats owned in your name or jointly. Legal owner if different
Make and year Value from registered owner Amount owed
a. $ $
b. $ $
c. $ $
(Continued on reverse) Page 1 of 2
Adopted for Mandatory Use DEFENDANT'S STATEMENT OF ASSETS Penal Code, § 1202.4(f)
Judicial Council of California
CR-115 [Rev. Jan. 1, 2020]
PEOPLE OF THE STATE OF CALIFORNIA vs. CASE NUMBER:
DEFENDANT:
12. List all real estate owned in your name or jointly:
Fair market value Amount owed
Address of real estate
a. $ $
b. $ $
OTHER PERSONAL PROPERTY (Do not list household furniture and furnishings, appliances, or clothing.)
13. List anything of value not listed above owned in your name or jointly (continue on attached sheet if necessary)
Description Value Address where property is located
a. $
b. $
c. $
ASSETS
14. List all other assets, including stocks, bonds, mutual funds, and other securities (specify):
15. Is anyone holding assets for you? Yes No If yes, describe the assets and give the name and address of the
person or entity holding each asset (specify):
16. Except for attorney fees in this matter and ordinary and routine household expenses, have you disposed of or transferred any
assets since your arrest on this matter? Yes No
If yes, give the name and address of each person or entity who received any asset and describe each asset (specify):
DEBTS
17. Loans (give details):
18. Taxes (give details):
19. Support arrearages (attach copies of orders and statements):
20. Credit cards (give creditor's name and address and the account number):
21. Other debts (specify):
Date:
(TYPE OR PRINT NAME) (SIGNATURE)
INTERPRETER'S STATEMENT
I, having been duly sworn or having a written oath on file, certify that I truly translated this form to the defendant in the language noted
below.
Language: Spanish Other (specify):
(INTERPRETER'S SIGNATURE) DATE
(TYPE OR PRINT INTERPRETER'S NAME) (CERTIFICATION NUMBER)
CR-115 [Rev. Jan. 1, 2020] Page 2 of 2
DEFENDANT'S STATEMENT OF ASSETS
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