In the    [  ] District    [  ] Justice    Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Prosecutorial Jurisdiction 

Financial Declaration for Restitution 

v. 

_______________________________ 
Case Number 

_____________________________________ 
Defendant 

_______________________________ 
Judge 

The following information is true, and I have omitted nothing that is relevant to my 
financial status. 

(1) 

Employment 

[  ] I am unemployed because: 

ity, State, Zip 

 
Name 

ddress 

hone 

mail 

  A

  C

  P

  E

                 

Financial Declaration for Restitution 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 1 of 7 

I am employed by: (Include self-employment.) 

Name of Employer  Doing Business As (DBA) 

Address & Telephone Number 

 

 

 

 

(2) 

Dependents (Include spouse, children or other dependents in your household.) 

[  ] The following people depend on me for support. 

Name 

Age 

Name 

Age 

Relationship 
to Me 

Relationship 
to Me 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)  Gross Monthly Income (Income before tax deductions) 

[  ] I have no income because: 

[  ] I have the following monthly income: (Print your pre-tax income in the boxes below. If 
directed to do so by the court, you must be able to produce evidence of the items listed, such as 
most recent pay stubs, federal and state tax returns, W-2 forms, or a work history report from the 
Department of Workforce Services. For income that changes from month to month, calculate the 
annual total and divide by 12 months to list a monthly average.) 

Source of Income 
Work (Including self employment, wages, salaries, commissions, 
bonuses, tips and overtime) 

Monthly Amount 

Rental Income 

Business Income 

Interest and Dividends 

Worker’s Compensation 

Financial Declaration for Restitution 

Retirement Income (Including pensions, 401(k), IRA, etc.) 

$ 

$ 

$ 

$ 

$ 

$ 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 2 of 7 

 

 

 

 

 

 

       

 

Source of Income 

Monthly Amount 

Private Disability Insurance  

Social Security Disability Income (SSDI) 

Supplemental Security Income (SSI) 

Social Security (Do not include SSDI or SSI) 

Unemployment Benefits 

Education Benefits 

Veteran’s Benefits 

Alimony 

Child Support 

Payments from Civil Litigation 

Victim Restitution 

Public Assistance (Including AFDC, welfare, etc.) 

Support from household members 

Support from non-household members 

Trust Income 

Annuity Income 

Other (Describe) 

Other (Describe) 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Total  $ 

(4)  Monthly Tax Deductions 

[  ] I have the following deductions from my income: (These are deductions required by 
law which you do not make voluntarily. There may be other funds withheld from your paycheck 
that you will report in Paragraph (6). If directed to do so by the court, you must be able to produce 
evidence of the items listed, such as most recent pay stubs, federal and state tax returns, W-2 
forms, or a work history report from the Department of Workforce Services.) 

Type of Deduction 

Amount 

Federal Income Tax 

State Income Tax 

Municipal Income Tax  $ 

FICA 

Medicare 

$ 

$ 

$ 

$ 

Total   $ 

Financial Declaration for Restitution 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 3 of 7 

(5) 

Disposable Monthly Income 

[  ] I have no income. 

[  ] My disposable monthly income is: 

$ 

- $ 

= $ 

 

 

 

 

 

 

Gross Monthly Income from (3) 

Minus Monthly Tax Deductions from (4) 

Equals Disposable Monthly Income 

(6)  Monthly Expenses (Include amounts withheld from your paycheck other than tax deductions 

reported in Paragraph (4). For expenses that change from month to month, calculate the annual 
total and divide by 12 to list a monthly average. Include amounts you pay for yourself and any 
spouse, children or other dependents in your household. If directed to do so by the court, you 
must be able to produce evidence of the items listed.) 

[  ] I am personally paying the following monthly expenses: 

Monthly Expense 

Amount 

Rent or mortgage 

Food and Household Supplies 

Clothing 
Transportation (Such as public transportation, automobile 
payments, insurance, gas, maintenance) 

Utilities (Such as electricity, gas, water, sewer, garbage) 

Telephone 

Credit Card Payments 

Loans and Other Debt Payments 

Health Care Expenses (Excluding insurance listed above)  $ 

Alimony 

Child Support 

Child Care 

Education 

Health Care Insurance  

Business Expenses 

Real Property Taxes 

Real Property Insurance 

Real Property Maintenance 

Other Insurance (Describe) 

Entertainment 

Financial Declaration for Restitution 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 4 of 7 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Monthly Expense 

Amount 

Laundry and Dry Cleaning 

Donations 

Gifts 

Health Insurance Premiums 

Life Insurance Premiums 

Union and other dues 

Garnishment or Income Withholding Order 

Retirement Deposits (Including pensions, 401(k), IRA, etc.)  $ 

Restitution ordered in other cases 

Other (Describe) 

Total  $ 

(7) 

Financial Assets You Own (If directed to do so by the court, you must be able to produce 
evidence of the items listed.) 

Asset 

Holder 
(Name & Address) 

Co-owner 
(Name & Address) 

Current Value 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

 

 

 

 

 

 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Total 

 

Bank or Credit Union Account 

Bank or Credit Union Account 

Stocks, Bonds, Securities, Money 
Market Account  

Stocks, Bonds, Securities, Money 
Market Account  

Money Owed to You 

Cash 
Other (Describe) 

 

 

 

 

 

 

 

Financial Declaration for Restitution 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 5 of 7 

 

 

 
 

 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Total  $ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

  Original Cost 

  Current Value 

 

$ 

  $ 
 

  $ 
 

First Mortgage or Lien Holder (Name & Address) 

Amount Owed 

Monthly Payments 

 
Second Mortgage or Lien Holder (Name & Address) 

Amount Owed 

Monthly Payments 

(9) 

Personal Property You Own. If directed to do so by the court, you must be able to 
produce evidence of the items listed.) 

Lien Holder 
(Name & Address) 

Current 
Value 

Amount 
Owed 

Monthly 
Payments 

  
In Whose Name? 

 

 

 

 
Date Acquired 
 

ddress 

  A

(8) 

Real Property You Own (If directed to do so by the court, you must be able to produce 
evidence of the items listed, such as mortgage statements, tax appraisal, etc.) 

Property (Such as vehicles, 
boats, trailers, major 
equipment, etc.) 
Vehicle (Year, Make, Model) 

Vehicle (Year, Make, Model) 

Intellectual property 

Precious metals or gems 

Jewelry with a value of 
$1,000 or more 

Other personal property 
with a value of $1,000 or 
more (Describe) 

 

 

 

 

 

 

Financial Declaration for Restitution 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 6 of 7 

(10)  Credit Available (If directed to do so by the court, you must be able to produce evidence of 

the items listed.) 

Credit Card 

Bank or Credit Union 

Credit Limit 

Credit Available 

$ 

$ 

$ 

Total  $ 

$ 

$ 

$ 

$ 

(11)  Debts You Owe (Do not include amounts you owe on property reported in Paragraphs (8) 
and (9). If directed to do so by the court, you must be able to produce evidence of the items listed, such 
as credit card statements, loan documents, leases, bills, etc.) 

Debt Owed To 
(Name & Address of Creditor) 

Purpose of Debt (Such 
as credit card, cash loan, 
installment payment, etc.) 

In Whose 
Name? 

Amount 
Owed 

Monthly 
Payments 

 

 

$ 

$ 

Total  $ 

$ 

$ 

$ 

(12)  Other 

[  ] The following facts also are relevant to my ability to pay restitution. 

 

 

 

 

 

 declare under criminal penalty under the law of Utah that everything stated in this document is true.  A 
false statement made in this financial declaration form is punishable as a third-degree felony under Utah 
Code Section 76-8-504. 

Signed at ______________________________________________________ (city, and state or country). 

 
Date 

 
Financial Declaration for Restitution 

Signature ► 

Printed Name 

 

 

Approved Boards of Judges May 14, 2013 
Revised April 11, 2022 

Page 7 of 7 

 

 

 

  I