Are you an employer looking for more information about the Mc 210 form? As a business owner, you may need to understand and complete this specific document when it comes to providing your employees with Workers' Compensation benefits. In this blog post, we’ll provide you with a rundown on all of the information related to filling out and filing the Mc 210 form. We'll also explain why understanding and following these guidelines is so important in order to ensure that your company remains compliant with applicable laws and regulations. Let's get started!
| Question | Answer |
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| Form Name | Mc 210 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | mc210 form online, mc 210 form, mc210 statement, form mc 210 defendants financial statement |
SUPERIOR COURT OF CALIFORNIA, COUNTY OF |
FOR COURT USE ONLY |
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STREET ADDRESS: |
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MAILING ADDRESS: |
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CITY AND ZIP CODE: |
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BRANCH NAME: |
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PEOPLE OF THE STATE OF CALIFORNIA v. |
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DEFENDANT: |
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DEFENDANT'S FINANCIAL STATEMENT AND NOTICE TO DEFENDANT |
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(check all that apply) |
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ELIGIBILITY FOR APPOINTMENT OF COUNSEL |
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REIMBURSEMENT FOR COST OF |
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CASE NUMBER: |
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ELIGIBILITY FOR RECORD ON APPEAL AT PUBLIC EXPENSE |
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1. a. |
Defendant's name: |
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d. Date of birth: |
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b. |
Other names used: |
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e. Telephone number: |
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f. Driver's license number: |
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c.Address:
2.Defendant's present employment:
a.Occupation:
b.Name of employer:
c.Address:
d. |
Gross pay per month: $ |
week: $ |
day: $ |
e. |
week: $ |
day: $ |
f.Name of union:
g.Name of credit union:
3.If defendant is not now working, state the name and address of defendant's last employer and the last date defendant was employed.
a.Name:
b.Address:
c.Last date of employment:
4. |
Defendant |
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is |
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is not |
married. |
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5. |
a. |
Spouse's name: |
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d. Date of birth: |
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b. |
Other names used: |
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e. Telephone number: |
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f. Driver's license number: |
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c.Address:
6.Spouse's present employment
a.Occupation:
b.Name of employer:
c.Address:
d. |
Gross pay per month: $ |
week: $ |
day: $ |
e. |
week: $ |
day: $ |
f.Name of union:
g.Name of credit union:
7.If spouse is not now working, state the name and address of spouse's last employer and the last date spouse was employed.
a.Name:
b.Address:
c.Last date of employment:
8.Dependents
Name |
Address |
Relationship |
Aqe |
Page 1 of 2
Form Approved for Optional Use
Judicial Council of California
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
APPOINTMENT OF COUNSEL AND REIMBURSEMENT
AND RECORD ON APPEAL AT PUBLIC EXPENSE
Pen. Code, § 987. 8 www.courtinfo.ca.gov
PEOPLE OF THE STATE OF CALIFORNIA v.
DEFENDANT:
CASE NUMBER:
9. |
Defendant |
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a. |
Unemployment and disability |
$ |
b. |
Social Security |
$ |
c. |
Welfare, TANF |
$ |
d. |
Veteran's benefits |
$ |
e. |
Worker's compensation |
$ |
f. |
Child support payments |
$ |
g. |
Spousal support payments |
$ |
h. |
All other income not elsewhere listed ... |
$ |
Total: $
OTHER MONTHLY INCOME |
Spouse |
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a. |
Unemployment and disability |
$ |
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b. |
Social Security |
..................................... |
$ |
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c. |
Welfare, TANF |
................................... |
$ |
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d. |
.................................Veteran's benefits |
$ |
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e. |
......................Worker's compensation |
$ |
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f. |
.........................Child support payments |
$ |
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g. |
...................Spousal support payments |
$ |
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h. |
All other income not elsewhere listed |
$ |
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Total: $
EXPENSES
10.Monthly expenses being paid by defendant alone or by defendant and spouse
a. |
Rent or house payments |
$ |
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f. |
Clothing and laundry |
$ |
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b. |
Car payments |
$ |
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g. |
.....................................................Food |
$ |
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c. |
Transportation payments |
$ |
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h. |
................................Support payments |
$ |
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d. |
Medical and dental payments |
$ |
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i. |
.............................Insurance payments |
$ |
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e. |
Loan payments |
$ |
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...j. Other payments (union, taxes, utilities) |
$ |
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11. Installment payments other than those listed in item 10. |
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Total |
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Name of Creditor |
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MonthIy Payment |
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Balance Owed |
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a. |
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$ |
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$ |
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b. |
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$ |
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$ |
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$ |
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$ |
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c. |
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$ |
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$ |
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d. |
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e. |
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$ |
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$ |
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Total: $ |
Total: $ |
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ASSETS
12.What do you own? (State value):
a. |
Cash |
$ |
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b. |
House equity |
$ |
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c. |
Cars, other vehicles and boat equity |
$ |
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(List make, year, and license number of each) |
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d. |
Checking, savings, and credit union accounts |
$ |
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(List name and account number of each) |
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e. |
Other real estate equity |
$ |
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f. |
Income tax refunds due |
$ |
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g. |
Life insurance policies (ordinary life, face value) |
$ |
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Length of ownership |
h. |
......Other personal property (jewelry, furniture, furs, stocks and bonds, etc.) |
$ |
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Total: $ |
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13.ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO DEFENDANT: If an attorney is appointed to represent you, the court will,
at the conclusion of the criminal proceedings, after a hearing, make a determination of your ability to pay all or a portion of the cost of the attorney. If the court determines that you are at that time able to pay, the court will order you to pay all or part of such cost. Such an order will have the same force and effect as a judgment in a civil action and will be subject to execution.
Declaration of Defendant
I declare under penalty of perjury that the foregoing is true and correct, and that I understand the notice contained in item 13, under the laws of the state of California.
Date:
(Signature of Defendant)
DEFENDANT'S FINANCIAL STATEMENT ON ELIGIBILITY FOR
Page 2 of 2
APPOINTMENT OF COUNSEL AND REIMBURSEMENT AND RECORD ON APPEAL AT PUBLIC EXPENSE