(A) In determining whether a defendant is unable to pay a fine forthwith, the court may require such defendant to file a petition, under oath, with the court, upon a form provided by the court, setting forth the financial condition of the defendant.
(B) Such form shall be a questionnaire, and shall include, but shall not be limited to: the name and residence of the defendant; his or her occupation, if any; his or her family status and the number of persons dependent upon him; his or her monthly income; whether or not his or her dependents are employed and, if so, their approximate monthly income; his or her banking accounts, if any; real estate owned by the defendant, or any interest he or she may have in real estate; income produced therefrom; any independent income accruing to the defendant; tangible and intangible personal property owned by the defendant, or in which he or she may have an interest; and a statement listing the approximate indebtedness of the defendant to other persons. Such form shall also include a payment plan of the defendant, if the court should exercise its discretion in permitting the payment of such fine and costs in installments or other conditions to be fixed by the court. At the end of such form there shall be printed in bold face type, in a distinctive color the following: “THIS STATEMENT IS MADE UNDER OATH. ANY FALSE STATEMENT OF A MATERIAL FACT TO ANY QUESTION CONTAINED HEREIN SHALL CONSTITUTE FALSE SWEARING AND SHALL BE AN OFFENSE AGAINST THIS SECTION. THE MAXIMUM PENALTY IS NOT TO EXCEED STATE LAW OR IMPRISONED FOR A TERM NOT TO EXCEED STATE LAW, OR BOTH.” A copy of the petition shall be retained by the defendant.
(C) If the defendant is unable to read or write, the court, or the Clerk, may assist the defendant in completing the petition and require him or her to affix his or her mark thereto. The consequences of the making of a false statement shall be explained to such defendant.
(D) Any defendant who shall knowingly make a false statement of a material fact to any question contained in the questionnaire authorized by this section shall be guilty of false swearing under this section and, upon conviction, shall be subject to a fine not exceeding that imposed by state law or imprisonment for a term not to exceed state law, or both.
(Prior Code, § 173.16)