IGS - Admin - Financial Evaluation Application

NEVADA INFORMATION AND GENERAL SERVICES AGENCY COLLECTIONS DIVISION COUNTY
An Application for a Financial Evaluation Form is being given to you to determine your ability to pay for any of the following reasons: requested by the Superior Court; you have requested Court Appointed Counsel to represent you in a court case; determine monthly payments for court ordered victim restitution; court ordered fines; probation costs; juvenile hall fees.
1. Fill out both sides of the form, as complete as possible.
2. If the information requested does not apply, put not applicable. (N/A)
THE FOLLOWING COPIES MUST BE SUBMITTED TO COMPLETE THE EVALUATION. DO NOT SEND ORIGINALS

THE FOLLOWING INFORMATION BELOW IS REQUIRED TO COMPLETE YOUR APPLICATION. IF YOU DO NOT PROVIDE ALL THE INFORMATON REQUESTED, YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE AND THE COURT WILL BE NOTIFIED THAT A JUST EVALUATION COULD NOT BE DETERMINED.
1. Copies of your last four pay check stubs. If you are receiving aid such as Welfare or Social Security Benefits, a copy of your most recent award letter stating your benefit amount must be submitted. If you are receiving Unemployment Benefits- must make copies of benefit stubs and show proof looking for work. If you are receiving any other income it must be reported.
2. Copies your last three months bank statements for checking, savings accounts, estate, or other type of Inheritance payments and any child support/alimony payments.
3. Copies of your mortgage/rent receipts, rental agreement, utility bills, telephone bills, cell phone bills. If listing credit card debt, must put name of company and amount owed. If you are living in a person's home and don't pay rent, we need a letter from that person stating you live there rent free.
4. Copy of last years Federal Tax return filed. If you are self-employed your must bring your 1099 or two most recent quarterly profit/loss statements.
5. Copy of your Driver's License or DMV identification card and your Social Security card.
File Upload

Upload the documents mentioned in points 1-5 (above)
Cancelof
This form must be returned to our office five days before your next court date; if no court date than 10 days frm the date you receive the form.

Financial Evaluation Instructions revised 6-1-17

Financial

INCOME SOURCE

Rows	APPLICANT’S INCOME	SPOUSE’S INCOME (if applicable):
Gross Monthly Wages (before deductions)
Net Wages (Take home pay after deductions)
Unemployment/State Disability
Social Security Benefits
Retirement
Welfare/AFDC
Child Support/Spousal Support
Food Stamps
Worker’s Compensation

Other Income Source?
Applicant's Income
Spouse's Income

Real Estate Assets

Rows	Address	Purchase Date	Purchase Price	Current Loan(s) On Property	Approximate Market Value
1)
2)
3)

Motor Vehicles: Cars, Trucks, Motorcycles, Mobile Homes, Boats, Airplanes, RVs, ATVs

Rows	Description (Year & Model)	Purchase Date	Purchase Price	Balance Owing	Financed By
1)
2)
3)

Deposit Accounts (Bank /Savings & Loan/Credit Union)

Rows	Name and Branch	Type of Account Checking/Savings/CD/Other	Balance
1)
2)
3)

Life Insurance

Rows	Company Name & Address	Policy Number	Policy Amount	Cash Value
1)

Other Assets - Tools of Trade, Stocks & Bonds, Jewelry, Furniture, etc

Rows	Type	Total Value
1)
2)

MONTHLY HOUSEHOLD EXPENSES
Are monthly household expenses shared with a person/person(s) other than your spouse?
Person’s Name

First NameLast Name
Relationship
Household Payment Type
Payment Amount
If you rent: Name, address & phone of landlord
Landlord Name

First NameLast Name
Landlord Address

Street Address

Street Address Line 2

CityState

Zip Code
Landlord Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Utilities

Rows	Cost
Electric
Gas
Water/Sewer
Phone
Auto Fuel
Auto Insurance
Court Ordered Support

Food for how many persons?
Cost of food for amount of persons
TOTAL (Utilities) + Food Cost

PLEASE LIST ALL OTHER MONTHLY PAYMENTS YOU ARE PRESENTLY PAYING

Rows	Name of Creditor	Reason for Account	Present Balance	Monthly Payment
1)
2)
3)
4)
5)
6)

I/We can pay at least $ Amount* per month beginning Date*

I/WE DO HEREBY SWEAR, UNDER PENALTY OF PERJURY, THAT THE INFORMATION I/WE HAVE PROVIDED FOR THIS “APPLICATION FOR FINANCIAL EVALUATION” IS TRUE AND CORRECT. WARNING: Perjury is a felony punishable to confinement in a State Prison. (Penal Code Sections 17[a], 118, 126, 127 and 672.

AUTHORIZATION TO RELEASE INFORMATION AND TO DISCLOSE FINANCIAL INFORMATION TO A GOVERNMENT AGENCY:

I/We hereby authorize the County of Nevada and its duly authorized representatives to request a credit report, to contact any employer, creditor, bank, savings & loan, Attorney at Law or governmental agency regarding my/our financial condition; and I/We also authorize any financial institution, as defined in the California Right to Financial Privacy Act, to disclose to the County of Nevada, Collections Division and its authorized representatives any information contained in my/our financial records. Said disclosable information shall include, but is not limited to, all accounts, assets, liabilities and financial transactions maintained by said financial institution.
Applicant Signature
Signature*
Date

MonthDayYear
Spouse's Signature
Signature*
Date

MonthDayYear
Should be Empty:

NEVADA INFORMATION AND GENERAL SERVICES AGENCY COLLECTIONS DIVISION COUNTY

APPLICANT

Applicant Contact Information

APPLICANT'S SPOUSE

Financial

MONTHLY HOUSEHOLD EXPENSES

If you rent: Name, address & phone of landlord