Guidelines for
Probation Officers
Supervising
Economic Crime Offenders (EC)
The Division of Probation Services
FY 2009
1
These Guidelines were compiled with the expertise and assistance of the Probation
Economic Crime Task Force. The members of this committee are:
Gail Prim – Committee Chair – Probation
Officer
Hubert Barton – Probation Officer
Carol Rigato – Collections Management
Diane Schulz- Probation Officer
Carmen Spond – Financial Services,
Cheryl Boor – Probation Officer
Michelle Doll – Probation Officer
Susan Gallegos – Probation Officer
Chris Gastelle – Probation Supervisor
Patricia Goecke – Probation Officer
Elizabeth Greer- Probation Officer
Stephanie Harbison – Probation Officer
Jeannette Hensel – Probation Officer
SCAO
Jamie Stapleton – Probation Officer,
Renee Stewart – Probation Officer
Karen Trujillo – Probation Officer
Sheri Wiles – Probation Officer
Jean Woodford– Colorado Attorney
General‟s Office
Debbie Zink – Probation Officer
Tracy Hernon – Probation Officer
Jim Hilgers – Probation Officer
Terri Lee – Collections Investigator
Paul Litschewski – Collections Program
Administrator
Shelli Mayberry – Collections Investigator
Ali Moaddeli – Probation Supervisor
Terri Morrison – Assistant Legal Counsel –
Robert Murphy – Probation Officer
Jeffrey Otto – Probation Supervisor
Kimberly Parsons- Probation Officer
Eric Peratt – Probation Supervisor
Scott Prendergast – Probation Supervisor
Jeanne Rael – Collections Investigator
SCAO
2
Guidelines for Probation Officers Supervising Economic Crime
Offenders
The Economic Crime Task Force was created to promote consistent and effective
supervision of economic crime offenders. Economic crime can encompass many types
of offenses. To properly identify this population for the purpose of specialized services
the following definition was agreed upon.
Definition:
“An offender whose criminal activity is motivated by greed for the purpose of financial
gain. In the commission of the crime, while in a position of trust, the offender will have
used deviance, deceitfulness, deception, manipulation and/or grooming techniques.”
Statement of Purpose:
The Colorado State Judicial Branch, Division of Probation Services, working with the
Probation Economic Crime Task Force supports comprehensive identification,
evaluation, supervision and financial monitoring of economic crime offenders under the
supervision of probation departments throughout the state. It is believed that guidelines
are essential to accurately identify persons who should receive a more intensive level of
supervision than that afforded to regular probation cases, to reduce recidivism, recover
restitution and to minimize further victimization from financial predatory behavior.
We realize that probation departments can only adopt these guidelines to the extent that
they have resources available to do so. Even so, it is believed that the materials that are
being provided in this document give probation officers the best tools to ensure
adequate supervision for high risk economic crime offenders.
The following Supervision Guidelines, Conditions of Probation specific to the Economic
Crime Offender, and the Financial Disclosure Form will assist supervising probation
officers to improve offender accountability and promote victim and community
reparation. As stated before, it is acknowledged that not all departments have the
resources to meet all of the recommended guidelines. However, incorporating some of
these practices will increase the effectiveness of supervision compared to none at all.
Selection Criteria: It is important to differentiate the true economic crime
offender from the common criminal. The following criteria should be used to
draw that distinction.
1. Economic Crime (EC) cases are those identified by the prosecution where the
incentive for committing the crime was greed. Non-violent crimes, concentrating on
such crimes as theft, fraud, forgery, and securities crimes.
2. EC offenders exhibit predatory behavior and will often seek out relationships with
vulnerable individuals that they can easily build trust with.
3
3. These cases carry extremely high amounts of restitution; usually with several
victims. EC cases may include the offense of Occupational Fraud. This offense
involves the use of one‟s occupation for personal enrichment through the deliberate
misuse or misapplication of the employing an organization‟s resources or assets.
Examples include Asset Misappropriates, Corruption or Fraudulent Statement.
(Association of Certified Fraud Examiners, “2004 Report to the Nation of
Occupational Fraud & Abuse)
4. EC crimes may involve individual victim(s), business or affinity groups as opposed to
“governmental” crimes such as unemployment or welfare fraud. This does not rule
out the assignment of cases involving one of these entities however, concentration
will be on cases involving individual victims where the financial loss is more
damaging.
5. Offender Assessment: At this time, there is no assessment tool available to
adequately assess the true economic crime offender. An economic crime offender
may score in the medium or even the low level on the LSI. When an offender scores
high on the LSI, it is usually because they have treatment issues that must be
addressed prior to the concentration of the payment of restitution. If they score low
on the LSI, the level of supervision is over ridden to a higher level depending on the
number of risk factors that are identified that are specific to economic crime
offenders (listed in the next section). If the offender scores out maximum, all
treatment issues relating to drugs/alcohol and mental health should have been
addressed and a period of stability experienced prior to placement with an ECU
officer. If accepted for EC supervision, we then override the low score using the
following risk factors and characteristics.
Risk Factors and Common Characteristics of Economic Crime Offenders
In addition to the characteristics listed above, the following risk factors and
characteristics can be used to differentiate the EC offender from other types of
criminals.
(Obviously, the more characteristics that are identified the higher risk offender you will be working
with.)
Prior criminal history of theft, fraud, bad checks, forgery
Civil cases with unmet judgments
Prior bankruptcy or considering bankruptcy.
Defendant is unemployed
Defendant takes little or no responsibility for offense – one or more of the
following rationalizations verbalized or assessed by PO: Looking for immediate
gratification, a sense of entitlement, lying about need or finances, reports feeling
unrecognized, under appreciated or taken advantage of.
Defendant has liquidated assets prior to sentencing
Dumping assets quickly (under selling)
Late on restitution payments
Payments not being made according to payment plan
Not complying with budget – bounced checks, bank fees assessed for NSF, cash
advances on credit cards or payday loans. Living beyond their means.
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Grooming techniques used on victims, multiple victims and/or at-risk victims
Pattern of disregard for rules/authority
Lengthy history of traffic violations
Victim stance or lack of empathy for victim
Noncompliance with tax laws.
Missed appointments
Floating checks
Cash advances from credit cards
Cash advances from paychecks
Pay day loans
Cashing out 401k, CD or other investment accounts
Dipping into savings
Looking for immediate gratification
Entitlement (I need, I deserve, I want)
Minimized offense
Feeling Unrecognized
Feeling under appreciated
Feeling taken advantage of
Borrowing money
Shoplifting
Selling food stamps
The following supervision model is driven by an offender‟s progress on
supervision rather than by a specific time frame.
Phase One – Accountability
Phase Two- Containment
Minimum of 90 days
Minimum of Nine months
Phase Three Maintenance
Minimum of Six Months
Meet with Collections Investigator
for payment plan and financial
review.
Minimum face-to-face
contact with the offender
every 60 days.
A minimum of one face-to-face
contact with offender every 30 days
Home/work visits per case
plan
One home visit within the first 60
days of supervision, thereafter by
case plan
Budget/payment review
every 30 days
Review of finances/budget every 30
days.
Employment contact/verification
within the first 30 days.
5
Minimum face-to-face
contact with the
offender every 90
days.
Home/work visits per
case plan
Prior to progressing to the next phase the defendant must be in
compliance with the terms and conditions of their probation.
1.
2.
3.
4.
5.
6.
Compliance must be shown as it relates to the case plan.
Must be holding stable full time employment
Must have stable living conditions
Must be making regular, significant monthly restitution payments per payment plan
There should be no unexcused reporting dates
Must be in compliance with conditions of treatment
Phase One
Focus - To establish the elements of containment through offender
accountability and financial disclosure.





Full financial investigation to include the review of all requested financial
documentation, which may include bank statements, tax returns, assets and
liabilities.
A formal case assessment must be completed with the standardized assessment
tool. Override, if necessary – see attached risk factors.
Employer letter acknowledging defendant‟s conviction and probation conditions
and outlining defendant‟s job responsibilities in current position. PO will verify
letter and make follow up phone call to defendant‟s direct supervisor or conduct a
work site visit.
Defendant will complete a case plan worksheet and/or other tool to measure
victim empathy.
All referrals made – theft class, victim empathy class, money management class,
Consumer Credit Counseling. MH evaluation, community service, polygraph
examination, debtor‟s anonymous
Phase Two
Focus – Maintenance of a containment network through monitored
budgeting practices and compliance with payments of restitution.
Defendant to provide budget with receipts and/or checking account statement
monthly. Goal for defendant to have a checking account and budget that meets
all financial requirements with no overdrafts.
Defendant to provide monthly verification of earnings to probation.
Defendant to complete all treatment requirements and be in compliance with
payment plan and budget.
Defendant to provide a credit report to probation annually.
PO to monitor for high risk behavior (see attached) and impose sanction.
Collections Investigator review at minimum annually – DOL report, credit report.
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Current with payment plan or garnishment in place.
Three months without payment – sanction imposed.
Changes in employment or position require a new employer notification letter.
Phase Three
Focus – To monitor compliance/consistency with budget, case plan and
payment plan.
Appointments with probation every 6 weeks to 2 months
Consider for transfer to Collections Investigator caseload for routine checks of
investment/income/earnings
Monthly verification of employment
SWI check every 6 months for new cases both criminal and civil.
Mail-in per case plan and/or district policy
Intermediate Sanctions
Daily reporting
Daily job search
Area Restrictions (golf courses, gambling, malls, restaurants, etc)
Computer searches
Voluntary payroll deductions
Attachment of Earnings –up to 50% of earnings withheld
Writs of attachment (garnish bank accounts)
Lien person property
Impose late fees
Not within their budget –pay difference to restitution the following month
Evaluations (mental health)
Referrals (debtors anonymous, gamblers anonymous, budgeting classes)
Financial review
Community service
A note about incentives or rewards: Incentives or rewards can include a lessening of the
supervision requirements, possibly even doing a TSUP option to another PO for regular
supervision reporting. Intermediate Sanctions, bulleted above, elevate the supervision
requirements in some way. This population of offenders is not as easy to reward as drug and
other types of offenders might be. They are usually not in treatment or providing UA’s. If they are
being required to submit to polygraphs as a way to monitor behavior, you may be able to lessen
the frequency of polygraphs.
It is important to remember that some people respond well to incentives and others see this as a
chance to return to former behavior. Each case needs to be assessed on an individual basis. If
the economic crime offender starts doing something wrong it is often going to be running another
scam of some sort.
7
Common referrals may include the following
Debtor‟s Anonymous (DA) http://www.debtorsanonymous.org/
Gambler‟s Anonymous (GA) http://www.gamblersanonymous.org/
Victim Empathy Classes
Cognitive Therapy
Individual Therapy
Budgeting/Debt Elimination Counseling
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County Court
District Court
County, State of Colorado
Court Address:
THE PEOPLE OF THE STATE OF COLORADO
V.
Defendant.
Attorney or Party Without Attorney: (Name & Address)
Phone Number:
FAX Number:
E-mail:
Atty. Reg. #:
COURT USE ONLY
________________________________
Case Number:
Judge:
Division.:
Courtroom:
Additional Terms and Conditions of Probation - Economic Crime
_______________________________________________________________________________________
The defendant will be supervised by the probation officer for a period of ________ months, and will
comply with the following conditions:
Termination: __________
In addition to all of the standard terms and conditions of probation, and unless otherwise authorized
by the probation department or the court, the following Economic Crime Terms and Conditions will
apply for the duration of your sentence.
1)
You shall not acquire any new debt or financial obligation and you will disclose any current
debts or financial obligations.
2)
You shall not invest or lend any money or extend any credit and you will disclose any current
investment, lending arrangement and / or extension of credit.
3)
You shall not enter into any financial contracts and / or arrangements and you will disclose any
current financial contracts and / or arrangements.
4)
You shall not enter into any contracts and / or policies of insurance or annuity and you will
disclose any current contracts or policies of insurance or annuity.
5)
You shall not open any checking and / or savings accounts and you will disclose any current
checking and / or savings accounts.
6)
You shall not open, control, or assume ownership in or any interest in any bank or brokerage
account, financial instrument or financial product and you will disclose any current account,
instrument or financial product.
7)
You shall not purchase or lease a vehicle and you will disclose ownership information for any
vehicle owned or leased by you or provided for your exclusive or occasional use by another person,
business or other legal entity.
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8)
You shall not enter into, participate in, or benefit from any real estate transaction and you will
disclose any current real estate owned, controlled, managed, leased, rented, or any option to
purchase, lease or rent.
9)
You shall not have access to or control of any assets, funds, or financial information of any
individual, group, business or other legal entity and you will disclose any current access or control of
assets, funds or financial information.
10)
You shall not manage or participate in managing any person, group, trust, legal entity,
business, or act as a fiduciary* for any such persons, groups, trust, or other legal entity and you will
disclose any current management or fiduciary relationships.
11)
You shall not be employed by, employ, or have any contact with any co-defendant in the present
offense.
12)
You shall not create a new business or acquire a new or existing business, work as a
subcontractor, act as a registered agent, or otherwise be self employed and you will disclose any
current control of or ownership interest in any business, any subcontractor , registered agent, or self
employment situation.
13)
You shall disclose the nature and duties of your employment. You will inform your employer in
writing of the nature and details of your offense and your status on probation.
14)
You shall furnish budgets and financial documentation of any and all sources of personal and
business assets, income and expenses.
15)
You shall furnish documentation of assets, income and expenses for all persons living in your
household.
16)
You shall furnish Federal and State income tax returns and any tax court judgments with all
attachments and schedules for the past 3 years and thereafter on a yearly basis or as requested. You
will authorize any inquiry to verify the accuracy of the returns, attachments and schedules filed.
Note that any arrangement made for payment of taxes or any other debt does not relieve you of court
ordered financial obligations.
17)
You shall furnish credit bureau reports from recognized credit reporting agencies as requested.
18)
You shall disclose any personal and / or business, pending or finalized bankruptcy action,
including any filing, dismissal, pleadings, schedules, attachments, or discharge of bankruptcy.
19)
You shall notify your probation officer of all pending civil actions immediately. You shall
provide documentation for all pending and final civil cases including all pleadings, motions, civil
judgments, liens and garnishments as requested.
20)
You shall allow your probation officer, supervision team or other trained person, to conduct
searches of computers, computer records, hard drives, storage devices and other electronic and / or
digital media owned by, provided for the use of, or otherwise utilized by you and you will furnish any
other documents and / or proofs relevant to the adequate analysis of your financial position. The
person conducting the search may include a non-judicial employee and you may be required to pay for
such a search.
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21)
You shall not be allowed to subscribe to any internet service provider, by modem, LAN, DSL or
any other internet access (to include, but not limited to access through satellite dishes, PDAs,
electronic games, web televisions, internet appliances and cellular/digital telephones) and shall not be
allowed to use another person’s internet access or access the internet through any venue until
approved by the supervision team. When access has been approved, you agree to sign, and comply
with, the conditions of the “Electronic Use Agreement”
22)
You may be required to obtain, cooperate in or submit to an independent financial audit by a
qualified professional approved by probation and it may be at your expense.
23)
You may be required to cooperate with and pay for a third party approved by probation to
document your income, obligations and financial affairs.
24)
You may be required to cooperate, participate in, successfully complete, and pay for any
economic crime and / or theft counseling, education, treatment, or victim empathy class or group.
25)
You may be required to cooperate in and pay for issue specific and / or maintenance polygraph
examinations.
26)
You shall be truthful and complete in all statements, disclosures and documents provided to
probation. All disclosures shall be in written form and approved by the probation officer.
Violations of the Additional Terms and Conditions of Economic Crime may result in sanctions
imposed by the probation department, a review of your non compliance in a probation or court
proceeding, a Hearing for Revocation for Violation of Probation with the imposition of sanctions and /
or incarceration, if the court finds a violation has occurred.
I have received an identical copy of these terms and conditions and I have read them carefully with full
understanding. I understand I must respond truthfully and completely to all inquiries and requests in
order to be in full compliance with these terms and conditions. I understand the consequences of any
violation of these terms and conditions.
By signing below I affirm and acknowledge my acceptance of these terms and conditions as an
integral component of my sentence for the economic crime(s) committed.
________________________________
Defendant
Date
____________________________________
Probation Officer
Date
By The Court: ____________________
Judge / Magistrate
_____________
Date
*fiduciary
A person, such as an investment manager, the executor or personal representative of an estate, a mortgage broker, a
financial planner or an employee of an organization, such as a bank, entrusted with the property of another party and in
whose best interests the fiduciary is expected to act when holding, investing, or otherwise using that party's property. The
key to determining whether an individual or an entity is a fiduciary is whether they are exercising discretion or control over
the finances, information or assets of another person or group.
11
Electronic Use Agreement for Economic Crime Offenders
Client:
______________
Supervising Officer/Designee: _______________________
By signing below, the above named client indicates (s)he understands (s)he has the right to refuse consent to
the items contained herein and that the client voluntarily agrees to be compliant with the following conditions:
A.
Client shall provide a complete and accurate inventory of all computers, computer-related
equipment, software packages and communications devices and services on an inventory form provided by the
Probation Department. The client agrees to ensure that all information on the inventory is complete, accurate
and current at all times and that (s)he will not use or access any electronic storage or communication device or
service not reported on the inventory form and specifically approved for use by the Probation Department.
B.
Client shall be prohibited from possessing, viewing or using materials related to, or part of, the
elements of his/her crime. Such materials include, but are not limited to, the following:
Images of financial documents, transaction blanks, or transaction instruments or devices.
Materials focused on the methods, creation, or use of devices or instruments of financial transactions.
_____ Materials focused on the methods, creation, or use of applications or devices used in computer
intrusion, „hacking‟, malware, computer fraud, credit card fraud, or identify theft at any level.
C.
Client shall be prohibited from using any form of encryption, cryptography, steganography,
compression, password protected files and/or other method that might limit access to, or change the
appearance of, data, applications and/or images without prior written approval from the Supervising
Officer/Designee. If, for work purposes, password protection is required on any system or files used by Client,
the password shall be provided to the Supervising Officer/Designee upon request.
D.
Client shall be prohibited from attempting or successfully altering or destroying records of computer
use. This includes, but is not limited to, deleting or removing browser history data regardless of its age,
emptying the Recycle bin, the possession of software or items designed to boot into or to utilize RAM, kernels,
alter or wipe computer media, defeat forensic software, or block monitoring software. This also includes a
prohibition against restoring a computer to a previous state or the reinstallation of operating systems.
E.
Client shall allow the installation of monitoring software and periodic examination of their computer at
their own expense to monitor compliance with the conditions of probation. The client has no expectations of
privacy regarding computer use or information stored on the computer if monitoring software is installed and
understands and agrees that information gathered by said monitoring software may be used against him/her in
any subsequent administrative or legal proceeding.
F.
Client specifically agrees to be responsible for all data, images and material on the computer and
voluntarily consents to announced or unannounced searches by the Supervising Officer/Designee to verify
compliance with these special conditions of supervision. The Client understands and agrees that his/her
computer, related equipment, communication, and storage devices are subject to seizure by Supervising
Officer/Designee if, during a search, any evidence of a violation or any evidence of a new crime is detected.
Client‟s Signature
_
Date
________________________________________
Supervising Officer‟s Signature
Date
12
FINANCIAL DISCLOSURE FORM *(Total Household)
1. Fill out form COMPLETELY
2. Attach documentation
3. Define answers marked N/A
Section 1. Personal Information
1. Full Name
2. Home Phone ________b. Cell Phone __________
Mailing Address
Email ___________________________________
Street Address
Education________________________________
City
State
Zip _______ Degree __________________________________
County of Residence_________________________ Training _________________________________
How long at this address? ____________________ Certification ______________________________
3. Marital Status: Married Separated Unmarried (Single, divorced, widowed)
4. Your Social Security No.
5. Your Date of Birth _________________________
6. Passport No.
Country ________7. Alien/Visa Registration No.
9. List others in the household and their relationship to you (i.e. child, parent, roommate, and spouse):
9.
Own Home Rent Other (specify, i.e. share rent, live with relative)
10. Have you ever declared Bankruptcy? Yes/No When? ________ Where? ______________________ Dismissed?
Yes/No Discharged? Yes/No Repayment Plan Details? ________________ Competed? Yes/No
Section 2. Employment Information
11. Your Employer
12.
Street Address________________________________
City_____________________ State_____ Zip ______
Length of employment _________________________
Occupation __________________________________
Hours per week _____ Paid:
Pay is based on a
weekly
Monthly Salary
bi-weekly
Spouse’s/Partner’s Employer ___________________
Street Address ______________________________
City ____________State ______ Zip_____________
Occupation _________________________________
Salary/Rate of Pay ___________________________
twice a month
Hourly Rate of $ _______
monthly
other:
13. Unemployed due to Disability Involuntary layoff at work other:
How long unemployed?
14. Previous Employer
Occupation
Dates Employed
If you are self-employed, are you current with your tax filings? Yes/No If not, please explain. ___________
_______________________________________________________________________________________
-prepared
*Please list additional current employers below:
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ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 6 months, or as
otherwise directed, from each employer. If self-employed, please include proof of self-employment income for the prior 6
months (e.g. invoices, commissions, sales records, income statement, bank statements, accounts/notes receivables, lines of credit
and credit cards).
Section 3. Monthly Household Income Information (Per CRS 16-18.5-104)
Gross Monthly Income from salary &
$
Social Security Benefits
wages, including commissions, bonuses,
overtime, self-employment, business
income, other jobs & monthly
reimbursement expenses.
$
SSDI
SSI
Unemployment & Veterans’ Benefits
$
Pension & Retirement Benefits
Public Assistance (TANF)
$
$
Miscellaneous Income
Royalties, Trusts & Other Investments
Dependent Children’s Monthly Gross
Income.
Source of Income:______________
Rental Income
Child Support from Others
Spousal Support from Others
Disability, Workers’
Compensation
Interest & Dividends
OtherTotal Gross Monthly Income
$
$
Contributions from Others
All other sources, i.e.
personal injury settlement,
non-reported income, etc.
$
Expense Accounts
$
Other $
Other Total Monthly Miscellaneous Income
Total Income
I.
$
$
$
$
$
$
$
$
$
$
$
ATTACHMENTS REQUIRED: Please provide proof of all sources of household income received for
the past 6 months (i.e. pay stubs, earnings statements), or as otherwise directed, including pension/social
security/other income from each payer, including any statements showing deductions.
Section 4. Monthly Deductions
Mandatory Deductions
Federal Income Tax
PERA/Civil Service
Medicare Tax
Cost Per
Month
$
$
$
Cost Per
Month
State/Local Income Tax
Social Security Tax
Other Total Mandatory Deductions
Voluntary Deductions
Life and Disability Insurance
Health, Dental, Vision Insurance
Premium
$
$
$
$
Cost Per
Month
Cost Per
Month
$
$
Stocks/Bonds
Retirement/Deferred Compensation
$
$
$
$
Garnishments
Other Total Voluntary Deductions
Total Monthly Deductions
$
$
$
$
Total number of people covered on Plan

Child Care
Flex Benefit Cafeteria Plan
II.
14
ATTACHMENTS REQUIRED: Please provide proof of ALL monthly expenses listed below (i.e.
mortgage/lease documentation, insurance policies, utility bills, hospital bills, auto loan).
Section 5. Monthly Household Expenses
A. Housing
Cost Per
Month
1st Mortgage
Insurance
(Home/Rental)
&
Property Taxes (not included in
Cost Per
Month
$
$
2nd Mortgage
Condo/Homeowner’s/Maintenance Fees
$
$
$
Other - ________________
$
$
mortgage payment)
Rent
Total Housing
B. Utilities and Miscellaneous Housing Services
Cost Per
Month
Gas & Electricity
$
Telephone (local, long distance, $
cellular & pager)
Cost Per
Month
Water, Sewer, Trash Removal
Property Care (Lawn, snow removal,
$
$
cleaning, security system, etc.)
Internet Provider, Cable & Satellite $
Other TV
Total Utilities and Miscellaneous Housing Services
$
$
C. Food & Supplies
Cost Per
Month
Groceries & Supplies
$
Cost Per
Month
Dining Out
Total Food & Supplies
D. Health Care Costs (Co-pays, Premiums, etc.)
Cost Per
Month
Doctor & Vision Care
$
Medicine & RX Drugs
$
Premiums (if not paid by employer)
$
$
$
Cost Per
Month
Dentist and Orthodontist
Therapist
Other Total Health Care
$
$
$
$
E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.)
Cost Per
Cost Per
Month
Month
Primary Vehicle Payment
$
Other Vehicle Payments
$
Insurance
&
Registration/Tax
Payments
Fuel, Parking, & Maintenance
$
$
(yearly amount(s)/12)
Bus & Commuter Fees
Other Total Transportation
15
$
F. Children’s Expenses and Activities
Cost Per
Month
Clothing & Shoes
Extraordinary Expenses i.e. Special
Needs, etc.
Tuition
$
$
$
Cost Per
Month
Child Care
Misc. Expenses, i.e. Tutor, Books,
Activities, Fees, Lunch, etc.
Other Total Children’s Expenses and Activities
G. Personal Education
-Please identify status:Full-time studentPart-time studentnot currently enrolled
Cost Per
Month
$
Other Tuition, Books, Supplies, Fees, etc.
Total Education
H. Maintenance & Child Support (that you pay)
Cost Per
Month
Spousal Maintenance
$
Child Support
Recipient: __________
Recipient: __________
Arrears: _____________
$
$
$
Recipient: __________
Recipient: __________
Arrears: _____________
Total Maintenance and Child Support
$
Cost Per
Month
$
Cost Per
Month
$
$
$
$
$
I. Miscellaneous (Please list on-going expenses not covered in the sections above)
Cost Per
Month
Recreation/Entertainment
$
Personal Care (Hair, Nail, Clothing, etc.)
Legal/Accounting Fees
$
Subscriptions(Newspapers,Magazines, etc.)
Charity/Worship
$
Movie & Video Rentals
Vacation/Travel/Hobbies
$
Investments (Not part of payroll deductions)
Membership/Clubs
$
Home Furnishings
Pets/Pet Care
$
Sports Events/Participation
$
Bankruptcy Repayment Plan
Court Costs in another jurisdiction
Other $
Other Other $
Other Other $
Other Total Miscellaneous
III.
Total Monthly Expenses (Totals from A – I)
16
$
Cost Per
Month
$
$
$
$
$
$
$
$
$
$
$
$
ATTACHMENTS REQUIRED: Please provide statements for all items listed below.
Section 6. Unsecured Debt
List unsecured debts such as credit cards, store charge accounts, loans from family members, back taxes owed to the
I.R.S., Unsatisfied Civil Judgments, Student Loans, etc. Include co-maker or signature of all accounts. Do not list
debts that are liens against your property, such as mortgages and car loans.
Minimum
Name of Creditor
Account
Date of
Balance
Principal Purchase(s) for Which Debt
Monthly Payment
Number
Balance
Was Incurred
Required / Actual
Paid
IV.
Unsecured Debt Balance
$
$
/
$
$
/
$
$
/
$
$
/
$
$
/
$
$
/
→Total Minimum Monthly Payment
*PLEASE ATTACH ADDITIONAL SHEETS IF MORE ROOM IS NEEDED.
Section 7. Financial Statement Summary
Total Gross Income (Enter line from Section 3.I.)
$ _____________
Total Monthly Deductions (Enter line from Section 4.II.)
$ _____________
Adjusted Monthly Net Income (3.I. minus 4.II.)
$ _____________
Total Monthly Expenses (Enter line from Section 5.III.)
$ _____________
Total Minimum Monthly Payment Required
- Debts Unsecured (Enter line from Section 6.IV.)
$ _____________
Adjusted Monthly Expenses and Payments (5.III. plus 6.IV.)
Monthly Net Income less Monthly Expenses and Payments
17
$ _____________
$ ______________
ATTACHMENTS REQUIRED: Please provide documentation of all above assets including mortgage agreements,
bank statements (including money market and brokerage accounts), quarterly statements from investments, statements
from life insurance policies, statements from lenders, etc. to support the above items.
Section 8. Assets
**You MUST disclose all assets correctly. By indicating “None”, you are stating affirmatively that you do
not have assets in that category. Please attach additional copies of this section to identify your assets, if
necessary.
A. Real Estate (Address or Property
Amount
Owed
Description and Name of Creditor/ Lender)
None
Total
$
$
$
$
$
$
$
$
Amount
Owed
(Year, Make, Model) (Name of Creditor/Lender)
None
C. Cash on Hand, Bank, Checking,
Savings, or Health Accounts (Name of Bank
Net Value/Equity
$
B. Motor Vehicles & Recreation Vehicles
Including Motorcycles, ATV’s, Boats, etc.
Total
Estimated Value as of
Today.
Value = what you could sell
it for in its current
condition.
Estimated Value as of
Today.
Value = what you could sell
it for in its current
condition.
Net Value/Equity
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Type of
Account
Account #
Balance as of Today
or Financial Institution)
None
$
$
$
$
Total
D. Life Insurance
Type of Policy
$
Face Amount of Policy
Cash Value today
(Name of Company/Beneficiary)
None
$
$
$
$
$
$
Total
18
$
E. Furniture, Household Goods, and Other
Estimated Value as of Today.
Value = what you could sell it for in its current condition.
Personal Property, i.e. Jewelry, Antiques,
Collectibles, Artwork, Power Tools, etc.
Identify Items and report in total.
None
$
Total
F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts
None
G. Pension, Profit Sharing, or Retirement Funds
None
$
Total
$
Total
$
H. Miscellaneous Assets: If you own any of the assets identified below, please check the appropriate box.
None
Business Interests
Stock Options
Money/Loans owed to you
IRS Refunds due to you
Country Club &
Livestock, Crops, Farm Pending lawsuit or claim by
Accrued Paid Leave (sick,
Other Memberships
Equipment
you
vacation, personal)
Oil and Gas Rights Vacation Club Points
Safety Deposit Box/Vault
Trust Beneficiary
Frequent Flyer Miles Education Accounts
Health Savings Accounts
Mineral and Water Rights
Annuities
Trusts
Other Other Total
$
Total Value/Balance of All Assets (A – H)
$
Acknowledgement and Agreement
The undersigned specifically acknowledges and agrees that: 1. All statements made in this application are made for the
purpose of requesting time to pay my assessed amounts, which are due immediately unless otherwise arranged. 2. The
Court Collections Investigator may make verification or re-verification of any information related to this worksheet at
any time, either directly or through a credit-reporting agency, from any source named in this application or other sources
as deemed necessary. 3. In the event my payments become delinquent, the Court, its agents or assigns, may, in addition to
all their other rights and remedies, report my name and account information to a credit reporting agency. 4. I understand
I may be subject to wage garnishment, arrest and incarceration, additional fees or costs or further action if I fail to pay
the assessed amount as agreed. 5. I certify and swear under penalty of perjury that the information provided in this
worksheet is true and correct as of the date set forth opposite my signature on this worksheet and acknowledge my
understanding that any intentional or negligent misrepresentation(s) of the information contained in this worksheet may
result in further action being taken against me by the court.
__________________________________________
Applicant’s Signature
__________________________
Date
19