Approved, SCAO

STATE OF MICHIGAN

CIRCUIT COURT
COUNTY

AFFIDAVIT CONCERNING
FINANCIAL STATUS - LEAVE TO APPEAL
GRANTED BY SUPREME COURT

Original - Circuit court
1st  copy  -  Prosecutor
2nd copy - Defendant

CASE NO.

COURT OF APPEALS:
CIRCUIT COURT:

Court  address

Court  telephone  no.

THE PEOPLE OF THE STATE OF MICHIGAN

v

Defendant name, address, and telephone no.

The following is information concerning my present financial status.

1. RESIDENCE

2. MARITAL STATUS
Single

Rent

Own

Live with parents

Room/Board

Prison

Married

Divorced

Separated

Dependents:

3. INCOME   a.  Employer name and address

b. Length of employment

Number

Number

d. Other income (State monthly amount and source, such as DSS, VA, rent, pensions, spouse, unemployment, etc.  If no income, state NONE.)

c. Average pay
weekly

Gross: $

monthly

every two weeks

Net: $

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.)

Subscribed and sworn to before me on

Date

My commission expires:

Date

Signature:

Notary public

Notary public, State of Michigan, County of

Signature

,

County, Michigan

Administrative  Order  2003-03

CC 293    (5/07)   AFFIDAVIT CONCERNING FINANCIAL STATUS - LEAVE TO APPEAL GRANTED BY SUPREME COURT



Affidavit Concerning Financial Status- Leave to Appeal Granted by Supreme Court

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan 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.

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About This Form:

• Sourced from www.courts.michigan.gov/appeals (2023-03)
• Page(s): 1
• Fields(s): 33
• Average fields per page: 33
• Reading Level: Grade 10
• LIST Grouping(s): Unknown

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