Address:
City:
State:
Zip:
Housing Type: Martial Status:
Gender: Ethnicity:
In Case of Emergency, Contact:
Relationship:
Phone Number:
Type:
Address:
City:
State:
Zip:
FINANCIAL DECLARATION
This statement of financial declaration will be used to determine your eligibility to pay for legal service fees and costs. Respond
to all items below. Incomplete applications will not be considered.
INCOME
ASSETS
MONTHLY EXPENSES (Actual or Estimates?
)
This statement of financial declaration will be used to determine your eligibility to pay for legal service fees and costs.
Are you current or former military?
I DECLARE UNDER PENALTY OF PERJURY ACCORDING TO THE LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED HEREIN IS TRUTHFUL AND ACCURATE.
Full Legal Name: Date: