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