LIST ALL PERSONS WHO LIVE WITH YOU AND THEIR RELATIONSHIP TO YOU: NAME AGE RELATIONSHIP Do you pay child support? ___ Yes ___ No If yes, what amount do you pay per month? Do you receive child support? ___ Yes ___ No If yes, what is the monthly amount paid/ordered to be paid to you? How much money do you have…? On your person: In the bank: At home: In the custody of the Warden: Elsewhere: Do you own a house, land, mobile home, other real estate? ___Yes ___No If yes: Original cost: $ Monthly mortgage payment: $ Do you pay rent? ___ Yes ___ No If so, amount per month? Do you own an automobile? ___ Yes ___ No If yes: Year Make Model Cost Monthly payment Amount still owed Do you own any other property or have any other assets? ___ Yes ___ No If yes, please describe:
LIST ALL PERSONS WHO LIVE WITH YOU AND THEIR RELATIONSHIP TO YOU: NAME RELATIONSHIP AGE Do you pay child support? ___ Yes ___ No If yes, what amount do you pay per month? Do you receive child support? ___ Yes ___ No If yes, what is the monthly amount paid/ordered to be paid to you? How much money do you have…? On your person: In the bank: At home: In the custody of the Warden: Elsewhere: Do you own a house, land, mobile home, other real estate? ___Yes ___No If yes: Original cost: $ Monthly mortgage payment: $ Do you pay rent? ___ Yes ___ No If so, amount per month? Do you own an automobile? ___ Yes ___ No If yes: Year Make Model Cost Monthly payment Amount still owed Do you own any other property or have any other assets? ___ Yes ___ No If yes, please describe:
PD_Application_2018.docx