Free (PDF) - Colorado

FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE

CJA23 D/CO Mod. 04/02

IN UNITED STATES DISTRICT COURT
THE UNITED STATES VS. FOR UNITED STATES DISTRICT COURT AT DENVER, COLORADO PERSON PRESENTED (Show your full name) 1 2 3 4 5 CHARGE/OFFENSE (Describe if applicable & check box) Felony Misdemeanor 6 7 8 9 Defendant - Adult Defendant - Juvenile Appellant Probation Violator Parole Violator Habeas Petitioner 2255 Petitioner Material Witness Other (Specify) Court of Appeals District Court
DOCKET NUMBERS

Magistrate

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
EMPLOYMENT Are you employed? Name and address of employer: IF YES, Monthly Income? $ Monthly Income $ Yes $ No Yes No Am Self-Employed

IF NO, Give month and year of last employment If married is your spouse employed? IF YES, Monthly Income? ASSETS

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, dividend, retirement or annuity payments,

OTHER INCOME

or other sources? IF YES, Give Amount Received and Identify the Sources

Yes Received

No Sources

CASH

Have you any cash on hand or money in savings or checking accounts?

Yes

No IF YES, State Total Amount $

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes Value IF YES, Give Value and Description No Description

PROPERTY

Marital Status Single

Total No. of Dependents

List persons you actually support and your relationship to them.

DEPENDENTS

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Married Widowed Separated/Divorced Apartment or Home Creditors $ $ $ $ Total Debt $ $ $ $ Monthly Pmt.

OBLIGATIONS AND DEBTS DEBTS AND MONTHLY BILLS (List all creditors, including banks, loan companies, charge accounts, etc.)

I certify under penalty of perjury that the foregoing is true and correct. Executed on (date): Signature of Defendant (or Person Represented) º
WARNING: A FALSE OR DISHONEST ANSWER TO A QUESTION IN THIS AFFIDAVIT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT, OR BOTH.