Approved, SCAO
Original - Circuit court 1st copy - Prosecutor 2nd copy - Defendant
STATE OF MICHIGAN CIRCUIT COURT COUNTY
Court address
AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT
CASE NO. COURT OF APPEALS: CIRCUIT COURT:
Court telephone no.
Defendant name, address, and telephone no.
THE PEOPLE OF THE STATE OF MICHIGAN
v
The following is information concerning my present financial status. 1. RESIDENCE Rent 2. MARITAL STATUS Single
Own
Live with parents
Room/Board
Prison
Number
Married
Divorced
Separated
Dependents:
Number
3. INCOME a. Employer name and address
b. Length of employment
c. Average pay weekly Gross: $
monthly
every two weeks Net: $
d. Other income (State monthly amount and source, such as DSS, VA, rent, pensions, spouse, unemployment, etc. If no income, state NONE.)
4. ASSETS (State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc. If no assets, state NONE. Attach an account statement
and certification for assets in prisoner accounts.)
5. OBLIGATIONS (Itemize monthly rent, installment payments, mortgage payments, child support, etc.)
Signature
Subscribed and sworn to before me on
Date
, Signature:
Notary public
County, Michigan
My commission expires:
Date
Notary public, State of Michigan, County of
Administrative Order 2003-03 CC 293 (5/07)
AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT