OCJA 23 Rev. 5/98
FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE IN UNITED STATES G MAGISTRATE G DISTRICT G APPEALS COURT or G OTHER PANEL (Specify below)
LOCATION NUMBER FOR
IN THE CASE OF
V.S.
AT
*
1 2 3 4 5
PERSON REPRESENTED (Show your full name)
*
CHARGE/OFFENSE (describe if applicable & check box ÿ)
G Felony G Misdemeanor
6 7 8 9
G G G G G G G G G
Defendant--Adult Defendant - Juvenile Appellant Probation Violator Parole Violator Habeas Petitioner 2255 Petitioner Material Witness Other
DOCKET NUMBERS Magistrate
*
District Court Court of Appeals
ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now
G Yes
G No
G Am Self-Employed
IF NO, give month and year of last employment How much did you earn per
ASSETS
9
Name and address of employer: IF YES, how much do you earn per month? $ If married is your Spouse employed? IF YES, how much does your Spouse earn per month? $
EMPLOYMENT
G Yes
G No
If a minor under age 21, what is your Parents or Guardian's approximate monthly income? $
Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No
RECEIVED SOURCES
OTHER INCOME
IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES
$
CASH
Have you any cash on hand or money in savings or checking
G
Yes
G No
IF YES , state total amount
PROPERTY
Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No
VALUE DESCRIPTION
IF YES, GIVE THE VALUE AND $ DESCRIBE IT
OBLIGATIONS & DEBTS
9
DEPENDENTS
9
MARITAL STATUS SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME:
Total No. of Dependants
9
Creditors
List persons you actually support and your relationship to them
DEBTS & MONTHLY BILLS
(LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.)
9
Total Debt $ $ $ $ $ $ $ $
Monthly Paymt.
I certify under penalty of perjury that the foregoing is true and correct. Executed on SIGNATURE OF
(OR PERSON REPRESENTED)
*