INSTRUCTIONS: DEFENDANT'S STATEMENT OF ASSETS

CR-117

A.  Name of Victim

The name of the victim who will receive restitution
goes here.

B.  Superior Court of California

Ask the clerk of your court or defendant’s attorney 
for this information.
C.  Name of Defendant

Write defendant’s name in the space provided.

D.  Case Number

Fill in the criminal case number assigned in the
space provided.

E.  Personal Information
a.  Defendant’s name.
b.  If defendant has previously used another
     name, provide that name in the space
     provided.
c.  Defendant’s date of birth. 
d.  Defendant’s social security number.
e.  Defendant’s marital status.
f.   Defendant’s driver license number and the
     state of issuance.
g.  Defendant’s home address. 
h.  Defendant’s home telephone number.
i.   Defendant’s employer's telephone number.

F.  Income and Occupation

List defendant’s sources of income and occupation. 
Include defendant’s job title and the name of the
division or office where defendant works or worked.

G.  Address of Employer

a.  Write the name and address of defendant’s
     business or employer.
b.  If defendant is not employed, write the
     names and addresses of all sources of
     income.
H.  Pay Period

Specify how often defendant is paid, that is, daily, weekly, monthly.

Specify defendant’s gross pay each pay period.

I.   Gross Pay

J.  Take-Home Pay

K.  Spouse’s Income

Specify defendant’s take-home, that is, after-taxes pay for each pay period.

If defendant is married and defendant’s spouse is employed, specify the name and address of his or her employer, job title, and
division or office.

L.  Other Sources of Income

If defendant has additional sources of income that have not been listed, write them here.

M.  Cash

N.  Accounts

Write the amount of money defendant has in cash.

Complete the required information regarding any money held in defendant’s name in accounts in banks and any other financial 
institutions.
O.  Automobiles

Complete the required information regarding any automobiles and boats defendant owns or jointly owns.

Form Approved for Optional Use 
Judicial Council of California CR-117 
[New January 1, 2004]

INSTRUCTIONS: DEFENDANT’S 
STATEMENT OF ASSETS

Page 1 of 2

www.courtinfo.ca.gov

P.  Real Estate

List all real estate owned in defendant’s name or
jointly

Q.  Other Personal Property

List any valuable property that has not already been 
mentioned that defendant holds in his or her name or 
jointly.
R.  Assets

List all other assets, including stocks, bonds, and
mutual funds.

S.  Assets Held for You

If anyone is holding any assets for defendant, check
the “yes” box and describe the assets along with the
name and address of each person or entity holding
the assets.

T.  Transfer of Assets

List any disposal or transfer of assets that defendant
has made since his or her arrest on this matter.

U.  Loans

If defendant has any outstanding loans, list them 
here. Give the details of the loan including why the 
loan was taken and to what institution defendant
owes money.

V.  Taxes

If defendant owes any past taxes, give the details
here.

W.  Support Arrearages

If defendant owes child or spousal support, attach
copies of the orders and statements to this form.

X.  Credit Cards

If defendant owes money on any credit cards, list
the name of each creditor and the account number.

Y.  Other Debts

Z.  Date and Signature

AA.  Interpreter

If defendant has any additional debts that have not yet been listed, write them down in the space provided.

Indicate the date and defendant’s name and have defendant sign in the spaces provided.

If an interpreter was used to complete the document, he or she must print his or her name, include his or her signature, and indicate
the date.

CR-117 [New January 1, 2004]

Page 2 of 2

INSTRUCTIONS: DEFENDANT’S 
STATEMENT OF ASSETS