CALIFORNIA VETERANS LEGAL TASK FORCE
PETITION TO PAY FEES (SCRAM, FCP, MCP, DVRP)

 

    First Name:       Middle Name:       Last Name: 

    Date of Birth (MM/DD/YYYY):      Criminal Case #: 

    Name of Attorney:                       Attorney Phone #:

    Date Ordered Into SCRAM (MM/DD/YYYY):                     Court Ordered Enrollment By (MM/DD/YYYY):

    Driver's License / Identification Card:     State:

    Phone Number:         Type:

    Email Address:

    Address:     City:     State:       Zip:

    Housing Type:          Martial Status:

    Gender:          Ethnicity:


    In Case of Emergency, Contact:     Relationship:

    Phone Number:     Type: 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

Employer: Phone Number:
Occupation: Date Began:
Monthly Net Pay: $
Spouses Monthly Net Pay: $
VA Service-Connected Monthly Disability Pay: $
VA Non-Service Monthly Pension: $
SSI/SSDI Monthly Income: $
Monthly Family Assistance: $
Other Income Source: $
   

TOTAL MONTHLY INCOME:

$

ASSETS

Cash on Hand: $
Checking Account Balance: $
Savings Account Balance: $
Credit Union Balance: $
Value of Home: $
Stocks/Bonds Value: $
Credit Card Available Balance: $
Automobile(s): $

Make/Model:

Year:   License:

Make/Model:

Year:   License:
   

TOTAL ASSETS:

$

 

MONTHLY EXPENSES (Actual or Estimates? )

Mortgage: $ Rent: $
Food: $ Clothing: $
Utilities: $ Cable TV: $
Dental: $ Child Care: $
Child Support: $ Auto Payment: $
Auto Fuel: $ Auto Insurance: $
Other Bills: $    
  List    
     
   

TOTAL MONTHLY EXPENSES:

$

This statement of financial declaration will be used to determine your eligibility to pay for legal service fees and costs.

 

MILITARY/VETERAN APPLICANTS ONLY

Your Branch of Service:                 Highest Rank:

Date Entered:                 Date Exited:

Discharge Characterization:

Current Guard or Reserve:             (If yes, branch/unit):

Deployments - Theater/Operation Date Deployed Date Returned Combat

 

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: