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Here is the text we could read:

FOR COURT USE ONLY

CR-105

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

DEFENDANT:

PEOPLE OF THE STATE OF CALIFORNIA v.

DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT 
(check all that apply)

ELIGIBILITY FOR APPOINTMENT OF COUNSEL 

REIMBURSEMENT FOR COST OF COURT-APPOINTED COUNSEL

ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE

1. a.
b.
c.

Defendant's name:
Other names used:
Address:

CASE NUMBER:

d.

e.

f.

Date of birth:

Telephone number:

Driver's license number:

Occupation:
Name of employer:
Address:
Gross pay per month: $ 
Take-home pay per month: $
Name of union:
Name of credit union:

Defendant's present employment:
a.
b.
c.
d.
e.
f.
g.
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:
Address:
Last date of employment:

week: $ 
week: $ 

day: $ 
day: $ 

b.
c.
Defendant                                            married.

is not

is

2.

3.

4.

5.

d.
e.
f.

Date of birth:
Telephone number:
Driver's license number:

a.

Spouse's name:

b.

Other names used:

c.

Address:

6.

Spouse's present employment

a.
b.
c.
d.
e.
f.
g.

Occupation:
Name of employer:
Address:
Gross pay per month: $ 
Take-home pay per month: $
Name of union:
Name of credit union:

week: $
week: $ 

day: $ 
day: $ 

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.
b.
c.

Name:
Address:
Last date of employment:

8.

Dependents

Name

Address

Relationship

Age

Form Approved for Optional Use 
Judicial Council of California 
CR-105  [Rev. September 1, 2018]

DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR 
APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND 
RECORD ON APPEAL AT PUBLIC EXPENSE

Page 1 of 2

Pen. Code, § 987. 8 
www.courts.ca.gov

9.

Defendant

OTHER MONTHLY INCOME

Spouse

PEOPLE OF THE STATE OF CALIFORNIA  v.
DEFENDANT:

a.
b.
c.
d.
e.
f.
g.
h.

Unemployment and disability  
Social Security   
Welfare, TANF    
Veteran's benefits 
Worker's compensation   
Child support payments 
Spousal support payments 
All other income not elsewhere listed  

 $
 $
 $
 $
 $
 $
 $
 $
 $

Total:

CASE NUMBER:

CR-105

a.
b.
c.
d.
e.
f.
g.
h.

Unemployment and disability  
Social Security   
Welfare, TANF    
Veteran's benefits 
Worker's compensation   
Child support payments 
Spousal support payments 
All other income not elsewhere listed  
Total: 

 $
 $
 $
 $
 $
 $
 $
 $
 $

EXPENSES

10. 

Monthly expenses being paid by defendant alone or by defendant and spouse
a.
b.
c.
d.
e.

Rent or house payments 
Car payments   
Transportation payments  
Medical and dental payments  
Loan payments 

f.
g.
h.
i.
j.

 $
 $
 $
 $
 $

11. 

Installment payments other than those listed in item 10.

Clothing and laundry
Food  
Support payments  
Insurance payments   
Other payments (union, taxes, 
utilities)

Total (a-j): 

 $
 $
 $
 $
 $
 $

Name of Creditor

MonthIy Payment

Balance Owed

a.
b.
c.
d.
e.

12. 

What do you own? (State value):
a.
b.
c.

Cash   
House equity   
Cars, other vehicles and boat equity (List 
make, year, and license number of each)

ASSETS

d.

e.
f.
g.
h.

Checking, savings, and credit union accounts 
(List name and account number of each)
Other real estate equity
Income tax refunds due  
Life insurance policies (ordinary life, face value)     
Other personal property (jewelry, furniture, furs, stocks and bonds, etc.)  

 $
 $
 $
 $
 $
Total:  $

 $
 $
 $

 $

 $
 $
 $
 $

Total:

 $

 $
 $
 $
 $
 $
Total:  $

Length of ownership

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

Defendant's Financial Statement on Eligibility for Appointment of Counsel and Reimbursement and Record on Appeal at Public Expense

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 129
Average fields per page: 64
Reading Level: Grade 7
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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Defendant's Financial Statement on Eligibility for Appointment of Counsel and Reimbursement and Record on Appeal at Public Expense

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