Form Cr-105 "Defendant's Financial Statement on Eligibility for Appointment of Counsel and Reimbursement and Record on Appeal at Public Expense" - California

Form CR-105 is a California Superior Court form also known as the "Defendant's Financial Statement On Eligibility For Appointment Of Counsel And Reimbursement And Record On Appeal At Public Expense". The latest edition of the form was released in September 1, 2018 and is available for digital filing.

Download an up-to-date Form CR-105 in PDF-format down below or look it up on the California Superior Court Forms website.

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CR-105
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PEOPLE OF THE STATE OF CALIFORNIA v.
DEFENDANT:
DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT
(check all that apply)
ELIGIBILITY FOR APPOINTMENT OF COUNSEL
REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL
CASE NUMBER:
ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE
1. a.
Defendant's name:
d.
Date of birth:
b.
Other names used:
e.
Telephone number:
c.
Address:
f.
Driver's license number:
2.
Defendant's present employment:
a.
Occupation:
b.
Name of employer:
c.
Address:
d.
Gross pay per month: $
week: $
day: $
e.
Take-home pay per month: $
week: $
day: $
f.
Name of union:
g.
Name of credit union:
3.
If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was
employed.
a.
Name:
b.
Address:
c.
Last date of employment:
4.
Defendant
is
is not
married.
5.
a.
Spouse's name:
d.
Date of birth:
e.
Telephone number:
b.
Other names used:
f.
Driver's license number:
c.
Address:
6.
Spouse's present employment
a.
Occupation:
b.
Name of employer:
c.
Address:
d.
Gross pay per month: $
week: $
day: $
e.
Take-home pay per month: $
week: $
day: $
f.
Name of union:
g.
Name of credit union:
7.
If spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed.
a.
Name:
b.
Address:
c.
Last date of employment:
8.
Dependents
Name
Address
Relationship
Age
Page 1 of 2
Form Approved for Optional Use
Pen. Code, § 987. 8
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
Judicial Council of California
www.courts.ca.gov
APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND
CR-105 [Rev. September 1, 2018]
RECORD ON APPEAL AT PUBLIC EXPENSE
CR-105
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PEOPLE OF THE STATE OF CALIFORNIA v.
DEFENDANT:
DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT
(check all that apply)
ELIGIBILITY FOR APPOINTMENT OF COUNSEL
REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL
CASE NUMBER:
ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE
1. a.
Defendant's name:
d.
Date of birth:
b.
Other names used:
e.
Telephone number:
c.
Address:
f.
Driver's license number:
2.
Defendant's present employment:
a.
Occupation:
b.
Name of employer:
c.
Address:
d.
Gross pay per month: $
week: $
day: $
e.
Take-home pay per month: $
week: $
day: $
f.
Name of union:
g.
Name of credit union:
3.
If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was
employed.
a.
Name:
b.
Address:
c.
Last date of employment:
4.
Defendant
is
is not
married.
5.
a.
Spouse's name:
d.
Date of birth:
e.
Telephone number:
b.
Other names used:
f.
Driver's license number:
c.
Address:
6.
Spouse's present employment
a.
Occupation:
b.
Name of employer:
c.
Address:
d.
Gross pay per month: $
week: $
day: $
e.
Take-home pay per month: $
week: $
day: $
f.
Name of union:
g.
Name of credit union:
7.
If spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed.
a.
Name:
b.
Address:
c.
Last date of employment:
8.
Dependents
Name
Address
Relationship
Age
Page 1 of 2
Form Approved for Optional Use
Pen. Code, § 987. 8
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
Judicial Council of California
www.courts.ca.gov
APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND
CR-105 [Rev. September 1, 2018]
RECORD ON APPEAL AT PUBLIC EXPENSE
CR-105
PEOPLE OF THE STATE OF CALIFORNIA v.
CASE NUMBER:
DEFENDANT:
OTHER MONTHLY INCOME
9.
Defendant
Spouse
a.
Unemployment and disability
$
Unemployment and disability
$
a.
b.
Social Security
$
Social Security
$
b.
c.
Welfare, TANF
$
Welfare, TANF
$
c.
d.
Veteran's benefits
$
Veteran's benefits
$
d.
e.
Worker's compensation
$
Worker's compensation
$
e.
f.
Child support payments
$
Child support payments
$
f.
g.
Spousal support payments
$
Spousal support payments
$
g.
h.
All other income not elsewhere listed
$
All other income not elsewhere listed
$
h.
Total:
$
Total:
$
EXPENSES
10.
Monthly expenses being paid by defendant alone or by defendant and spouse
a.
Rent or house payments
$
f.
Clothing and laundry
$
b.
Car payments
$
g.
Food
$
c.
Transportation payments
$
h.
Support payments
$
d.
Medical and dental payments
$
i.
Insurance payments
$
e.
Loan payments
$
j.
Other payments (union, taxes,
$
utilities)
$
Total (a-j):
11.
Installment payments other than those listed in item 10.
MonthIy Payment
Balance Owed
Name of Creditor
a.
$
$
b.
$
$
c.
$
$
d.
$
$
e.
$
$
Total: $
Total: $
ASSETS
12.
What do you own? (State value):
a.
Cash
$
b.
House equity
$
c.
Cars, other vehicles and boat equity (List
$
make, year, and license number of each)
d.
Checking, savings, and credit union accounts
$
(List name and account number of each)
e.
$
Other real estate equity
f.
$
Income tax refunds due
g.
$
Length of ownership
Life insurance policies (ordinary life, face value)
h.
$
Other personal property (jewelry, furniture, furs, stocks and bonds, etc.)
Total:
$
13.
ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO DEFENDANT: If an attorney is appointed to represent you,
the court will, at the conclusion of the criminal proceedings, after a hearing, make a determination of your ability to pay all or a
portion of the cost of the attorney. If the court determines that you are at that time able to pay, the court will order you to pay all or
part of such cost. Such an order will have the same force and effect as a judgment in a civil action and will be subject to execution.
Declaration of Defendant
I declare under penalty of perjury that the foregoing is true and correct, and that I understand the notice contained in item 13, under the
laws of the state of California.
Date:
SIGNATURE OF DEFENDANT
CR-105 [Rev. September 1, 2018]
Page 2 of 2
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND
RECORD ON APPEAL AT PUBLIC EXPENSE
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