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___ per week or

___ per month

___ per week or

___ per month

Employer Information Employer Phone Number Supervisor’s Name Street Address: City, State, Zip Hours worked Pay rate Spouse’s Employer Street Address: City, State Zip Hours worked Pay rate Adult in Household’s Employer Street Address: City State Zip Hours Worked Pay Rate

____per week or

____ per month

If unemployed, list: Length of time unemployed Name of previous employer Street Address of previous employer: City, State, Zip

Defendant’s Financial Information

Public Assistance Are you currently receiving (check all that apply) ___ Food Stamps ___ Medicaid ___ Public housing ___ Temporary Assistance to Needy Families (TANF) ___ Supplemental Security Income (SSI)

Income (Monthly)

Take Home Pay Spouse’s Take Home Pay Investment Income

Stock Dividend Bond Dividend Rental Income Pension Payments Unemployment Social Security Benefits Child Support Public Assistance

TANF SSI Medicaid Other Cash Gifts Other (Describe)

TOTAL GROSS MONTHLY INCOME

Monthly Amount

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