Coryell County Juvenile Probation Department

Financial Applicationfor:

Juvenile’s Name/DOB: ______

Cause Number: ______

Offense/s: ______

Please complete this financial application to the best of your knowledge.

Do not sign the back page until in the presence of a Notary.

The person listed as PARENT REQUESTINGASSISTANCEmust be the person who is present at the time the financial form is notarized. Have the statement notarized by the Coryell County Juvenile Probation Department staff (if possible).

Be sure to attach a copy of the last 3 year’s tax returns, all current year to date pay stubs and any and all documentation to support your claim of indigence or disability.

If Military, you must provide a copy of your leave and earnings statement.

Financial Application

All blanks must be completed. Sections not pertaining to your situation willbe completed with “N/A” or “None”.

I.PERSON Requesting Assistance:

Name: ______

Relationship to juvenile: __biological parent; __adopted parent; __guardian; __grandparent; other ______

Address: ______

(Street number, apartment or lot, city, state and zip)

Mailing Address: ______

(If same as street address, write “same”)

Home Phone: (____)______Date of Birth: ______

Marital Status: ______

Are you on Medicaid? Yes______No______

Is anyone in your home on Medicaid? Yes ____ Names: ______

No ____

Employed? Yes______No______If yes, complete employer information below. If no, mark with “N/A”.

Employer: ______

(Write employer’s business name)

Employer’s Address: ______

(Street number, city, state and zip)

Business Phone: (______)______YourGross Monthly Salary: $______

Are you receiving unemployment compensation? Yes______No______.

If yes, complete information below. If no, mark each blank with “N/A”.

Amount: $______How received? ______(weekly, monthly, etc.)

II.SPOUSE:

Name: ______

Relationship to juvenile: __biological parent; __adopted parent; __step-parent; __guardian; __grandparent; other ______

Address: ______

(Street number, apartment or lot, city, state and zip)

Mailing Address: ______

(If same as street address, write “same”)

Home Phone: (______)______Date of Birth: ______

Marital Status:______

Employed? Yes_____ No_____ If yes, complete employer information below. If no, mark with “N/A”.

Employer: ______

(Write employer’s business name)

Business Phone: (______)______SpousesGross Monthly Salary: ______

Are you receiving unemployment compensation? Yes_____ No_____.

If yes, complete information below. If no, mark each blank with “N/A”.

Amount: $______How received? ______(weekly, monthly, etc.)

III. NATURAL PARENT LIVING OUTSIDE THE HOME

(Answer all known questions)

Name: ______

Address: ______

(Street number, apartment or lot, city, state and zip)

Mailing Address: ______

(If same as street address, write “same”)

Home Phone: (____)______Date of Birth: ______

Marital Status: ______

Employer: ______

(Write employer’s business name)

Employer’s Address: ______

(Street number, city, state and zip)

Business Phone: (____)______

IV.OTHER DEPENDANTS LIVING IN HOUSEHOLD: (List by name, DOB, and relationship to you. Use another sheet marked IV to continue if necessary).

NameDate of BirthRelationship

______

______

______

______

V.OTHER INCOME/ASSETS (Put $0 if not applicable)

Child Support: $______

SSI:$______(for whom & type- )

$______(for whom & type- )

$______(for whom & type- )

VA Disability:$______

Foster parent income:$______

TANF/WIC: $______

Food Stamps (SNAP):$______

Retirement Pay: $______

Other:$______

Interest Bearing Accounts/Investments: $______

Financial contribution to household from another: $______

Savings Accounts: $______Stocks and Bonds: $ ______

Cash on hand: $ Individual Retirement Account:$______

Checking account(s):$ Mutual Funds:$______

Certificates of Deposit:$______Safe deposit box:$______

College funds:$ Other Funds:$______

Life Insurance-cash value $______

What automobiles do you have?

(1)Year ______Make and Model ______Debt______

(2)Year ______Make and Model ______Debt______

(3)Year ______Make and Model ______Debt______

Do you have any motorcycles, boats or other recreational vehicles? If so, please describe: ______

______

Property / Location of property / payment/balance / owed/value
a)Home (primary residence)
b)2nd Home/Rental Property
c)Other Land/buildings

VI. MONTHLY EXPENSES/DEBTS (Put $0 if not applicable)

  1. Rent/mortgage: $______

b. Utilities (gas, water, electricity): $______

c. Food: $______

d. Telephone: $______

  1. Vehicle Payment(s): $______
  2. Vehicle(s) Insurance: $ ______
  3. Vehicle gas: $______
  4. Health Insurance: $______
  5. Credit Cards: $______
  6. Child support payment: $______
  7. Loans: $______
  8. Cable/Internet: $______
  9. Other expenses: $______
  10. Other expenses: $______
  11. Other expenses: $______

TOTAL MONTHLY EXPENSES $______

VII.REMARKS: (Any unusual family obligations or expenses, explanations, etc.)

______

STOP: This form must be signed in the presence of a Notary Public to be valid.

I, ______, hereby state under oath that the foregoing Financial Application and the facts and statements contained therein, are true and correct to the best of my knowledge of same. I further declare that I have no ability to obtain credit or to raise funds with which to employ an attorney and request the court to appoint an attorney to represent my child in court. I also understand that falsification of this financial statement in whole or in part, may result in prosecution of Perjury and other Falsification as set forth in chapter 37, Texas Penal Code.

______

Signature of Person Requesting Assistance

Subscribed and sworn to before me, the undersigned Notary Public on this day of ______, 201___.

______

Notary Public

______

Typed or Printed Name of Notary

Commission expires: ______

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CCJPD10/2017