Free Financial Affidavit (CJA23) - Alaska

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OCJA 23
Rev. 5/98 IN THE CA SE FOR

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FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYM ENT OF FEE
IN UNITED STATES
MAGISTRATE D I ST R IC T APPEA LS CO URT or O T H E R P A N EL (S p ec if y b el ow ) LOCATION NUMBER

V.S.
AT

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1 2 3 4 5 De fenda nt-- Ad ult De fenda nt - Juv enile Appellant Probation Violator Parole Violator Habeas Petitioner 2255 Petitioner Material Witness Other DOCKET NUMBERS M agistra te

PERSO N RE PRESE NTE D (Show your full name)

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CHA RGE /OFFENSE (describe if applicable & check box ÿ) Felony Misdemeanor

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Distric t Co urt

6 7 8 9

Co urt of A ppe als

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now Yes No Am Self-Employed Nam e and address of em ployer:
EMPLOYMENT

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? $ Yes

IF NO, give month and year of last employment How much did you earn per month? $ 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 Yes No the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? ASSETS OTHER INCOME
RECEIVED SOURCES

IF YES, GIVE THE AMOUNT RECEIVED & IDENT IFY THE SOURCES

$
Yes No IF YES, state total amount $

CASH

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

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

9

PROPERTY

VALUE

D E S CR I PT I ON

IF YES, GIVE THE VALUE AND $ DESC RIB E IT

M A R I T A L ST A T U S S IN G L E

Total No. of De pen den ts

List persons you actually support and your relationship to them

DEPENDENTS

MARRIED WIDOWED

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OBLIGATIONS & DEBTS DEBTS & MONTHLY BILLS
(LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.)

S E P AR A T E D O R DIVORCED APARTMENT OR HOME:

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Cre ditors $ $ $ $ Total Debt $ $ $ $ M onthly Pay mt.

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I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)

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