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No.

______________________

In the

Court

_________________________________

___________________

vs.

______________________________

________________________

County

AFFIDAVIT OF FINANCIAL INFORMATION

All information must be completed by the defendant and must be current, accurate, and true. Intentionally or knowingly giving false information may result in your prosecution for the offense of aggravated perjury, a felony. The punishment for aggravated perjury includes imprisonment not to exceed ten (10) years and a fine not to exceed ten thousand dollars ($10,000). Please fill in all blanks. If you do not know the information being asked, enter DO NOT KNOW in the blank. If the information being asked does not apply to you, enter N/A in the blank.

Defendant’s Personal Information

ame Phone Number Street Address City, State, Zip Social Security # Driver’s License # Date of Birth

ame of Spouse ame of Other Adults Living in Household

Dependents: ame(s) (list below):

Age

Relation

Income

Are you currently in jail or in a correctional institution?

___ ___

No Yes

If yes, provide name of institution:

Are you currently residing in a mental health facility?

___ ___

No Yes

If yes, provide name of facility:

Do you have an application pending at a mental health facility?

___ ___

No Yes

If yes, provide name of facility

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