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In the [ ] District [ ] Justice Court of Utah
__________ Judicial District ________________ County
Court Address ______________________________________________________
_____________________________________
Plaintiff
_____________________________________
Defendant
Declaration of Financial Status
(Criminal)
(Utah Code 78B-22-201.5)
_______________________________
Case Number
_______________________________
Judge
I request a court appointed lawyer. My date of birth is ___________________.
Single [ ] Married [ ] Widowed [ ] Divorced [ ]
For each person you are legally required to support, list their age and your
relationship to them:
Name (and any aliases)
Address
City, State, Zip
Phone
Email
v.
Dependents
Your marital
status:
Total number of
dependents/
children:
____________
Age
Relationship
1001CRJ Approved January 18, 2022
Declaration of Financial Status (Criminal)
Page 1 of 3
Income
Employment
Are you employed: YES [ ] NO [ ] Self-employed [ ]
Employer:______________________________ Hourly rate: ___________
Full time [ ] Part time [ ] Average hours per week: __________
Spouse
If married, is your spouse employed: YES [ ] NO [ ]
Employer:______________________________ Hourly rate: ___________
Full time [ ] Part time [ ] Average hours per week: __________
Other income
If not employed,
do you have
income from
another source?
Retirement
Alimony
Child support
Public assistance (not including food stamps)
SSI/Disability
Unemployment
Other
Total Income:
Total pay from all sources during the last 6 months
Assets
(In any
location/state)
Total cash (savings or checking)
Total value of land, house(s), or real property in your name
(include assets held for your benefit)
Total market value of vehicles
Make/Model
Total retirement accounts
Stocks, bonds, notes
Any other items (list)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Assets:
Debts
Creditors (to
whom you owe
money)
$
$
Total owed:
Monthly payment:
Collateral (auto, house, etc.)
$
$
1001CRJ Approved January 18, 2022
Declaration of Financial Status (Criminal)
Page 2 of 3
$
Monthly
Expenses
$
Housing
Food
Utilities
Medical
School
Clothing
Transportation
Debt payments
Necessities (list)
Child support
Alimony
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other (include fines, fees, or restitution you are required to pay)
Attorney fees you are required to pay from other cases
Total Expenses
I have these extraordinary financial conditions that prevent me from hiring a private lawyer (explain):
____________________________________________________________________________________
____________________________________________________________________________________
I may be subject to criminal penalties for making any false statements in this declaration. I authorize the
government agency that is responsible for providing lawyers to people who cannot pay in criminal cases
to contact me or request information from me or a third party to verify whether I can afford a private
lawyer. I may be ordered to pay the cost of my court appointed lawyer if the court later determines that I
am able to pay. I declare under criminal penalty under the law of Utah that everything stated in this
document is true.
Signed at ______________________________________________________ (city, and state or country).
Signature ►
Printed Name
1001CRF Approved December 13,
2021
Declaration of Financial Status (Criminal)
Page 3 of 3
Date
Declaration of Financial Status (Criminal)
This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah 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 legacy.utcourts.gov (2023-03)
- Page(s): 3
- Fields(s): 44
- Average fields per page: 14
- Reading Level: Grade 11
- LIST Grouping(s):
GO-00-00-00-00.
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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.
name_aliases was name__and_any_aliases (0.69 conf)users1_address_line_one was address (1.00 conf)city_state_zip was city__state__zip (0.35 conf)users1_phone_number was phone (1.00 conf)email was email (0.38 conf)page_field__1 was page_0_field_5 (0.31 conf)district_justice_court_utah was in_the_district_justice_court_of_utah (0.40 conf)page_field__2 was page_0_field_7 (0.31 conf)declaration_financial_status was declaration_of_financial_status (0.54 conf)plaintiff was plaintiff (1.00 conf)docket_number was case_number (1.00 conf)judge was judge (0.39 conf)defendant was defendant (1.00 conf)page_field__3 was page_0_field_13 (0.31 conf)children was children (0.34 conf)page__1 was page_1_of_3 (0.42 conf)judicial_district was judicial_district (0.38 conf)page_check__1 was page_0_check_1 (0.33 conf)single_married_widowed was single_married_widowed_divorced (0.33 conf)relationship was relationship_to_them (0.42 conf)request_court_lawyer_date was i_request_a_court_appointed_lawyer__my_date_of_birth_is (0.47 conf)page_check__2 was page_0_check_5 (0.33 conf)time_part_average_hours_per was full_time_part_time_average_hours_per_week (0.39 conf)employer was employer (0.39 conf)page_field__4 was page_1_field_2 (0.36 conf)page_field__5 was page_1_field_3 (0.36 conf)page_field__6 was page_1_field_4 (0.36 conf)af_f was AFF027 (0.51 conf)page__2 was page_2_of_3 (0.42 conf)employed_yes_self was are_you_employed__yes_no_self_employed (0.37 conf)page_check__3 was page_1_check_1 (0.26 conf)page_check__4 was page_1_check_2 (0.26 conf)hourly_rate was hourly_rate (0.31 conf)married_spouse_employed_yes was if_married__is_your_spouse_employed__yes_no (0.44 conf)page_check__5 was page_1_check_5 (0.26 conf)page_check__6 was page_1_check_6 (0.26 conf)page_check__7 was page_1_check_7 (0.26 conf)retirement was retirement (0.44 conf)financial_conditions_private was i_have_these_extraordinary_financial_conditions_that_prevent_me_from_hiring_a_private_lawyer__explain (0.44 conf)signed was signed_at (0.36 conf)city_state_country was city__and_state_or_country (0.47 conf)signature_date was date (1.00 conf)users1_signature was signature (1.00 conf)page__3 was page_3_of_3 (0.42 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
Suggested Screen 1:
Suggested Screen 2:
district_justice_court_utahjudicial_districtrequest_court_lawyer_date
Suggested Screen 3:
Suggested Screen 4:
Suggested Screen 5:
Suggested Screen 6:
Suggested Screen 7:
name_aliasespage_field__1page_field__2page_field__3page__1page_check__1page_check__2time_part_average_hours_perpage_field__4page_field__5page_field__6page__2page_check__3page_check__4page_check__5page_check__6page_check__7page__3
Suggested Screen 8:
Suggested Screen 9:
Suggested Screen 10:
single_married_widowedemployed_yes_selfmarried_spouse_employed_yes
Suggested Screen 11:
city_state_zipdeclaration_financial_statusretirementfinancial_conditions_privatecity_state_country
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