Form 9-301A. Pretrial release financial affidavit.

[For use with District Court Rule 5-401 NMRA, Magistrate Court Rule 6-401 NMRA, Metropolitan Court Rule 7-401 NMRA, and Municipal Court Rule 8-401 NMRA] STATE OF NEW MEXICO [COUNTY OF _______________] [CITY OF ________________] __________________ COURT STATE OF NEW MEXICO [COUNTY OF _______________] [CITY OF ________________] v. No. __________ _______________________________, Defendant. PRETRIAL RELEASE FINANCIAL AFFIDAVIT (This form may be used to gather the available information concerning the defendant’s employment status, employment history, and financial resources available to secure a bond.) INCOME & ASSETS A. EMPLOYMENT Are you now employed? Yes ___ No ___ If yes, please provide the name and address of employer. __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ How much do you earn per month? _____________________________________________________ If no, give month and year of last employment. ____________________________________________ How much did you earn per month? _____________________________________________________ Do you receive unemployment benefits? Yes ___ No ___ If yes, how much do you receive per month? _____________________________________________ If married, is your spouse employed? Yes ___ No ___ If yes, how much does your spouse earn per month? ______________________________________ B. PUBLIC ASSISTANCE Do you receive public assistance? Yes ___ No ___ If yes, please check the applicable programs and list how much you receive per month. Department of Health Case Management Service (DHMS) __________________________________ Temporary Assistance for Needy Families (TANF) _________________________________________ General Assistance (GA) _______________________________________________________________ Food Stamps __________________________________________________________________ _______ Medicaid __________________________________________________________________ ___________ Public Housing __________________________________________________________________ _______ Social Security Income/Social Security Disability Income __________________________________________________________________ ____________________ VA Disability __________________________________________________________________ _________ C. OTHER INCOME Have you received within the past 12 months any income from other sources? Yes ___ No ___ If yes, give value and description for each. __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ D. ASSETS Do you have any cash on hand or money in savings or checking accounts? Yes ___ No ___ If yes, total amount? _______________________________________________________________ Do you own any real estate, automobiles, or other valuable property (excluding ordinary household furnishings)? Yes ___ No ___ If yes, give value and description for each. __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ OBLIGATIONS & DEBTS A. DEPENDENTS List persons you actually support and your relationship to them. __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ B. MONTHLY EXPENSES House payment/rent ______________________________________________________ Utilities _________________________________________________________________ Groceries (after food stamps) _______________________________________________ Car payment ____________________________________________________________ Gas ___________________________________________________________________ Insurance ______________________________________________________________ Child care ______________________________________________________________ Student and consumer loans _______________________________________________ Court-ordered family support obligations ______________________________________ Other court-ordered payments ______________________________________________ Medical expenses ________________________________________________________ Other __________________________________________________________________ I hereby swear or affirm that the above information regarding my financial condition is correct to the best of my knowledge. I hereby authorize the court to obtain information from financial institutions, employers, relatives, the federal internal revenue service and other state agencies. ___________________________ Defendant’s Signature __________________ Date ___________________________ Defendant’s Printed Name