Free Motion to Appoint Counsel - District Court of Arizona - Arizona

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Case 2:04-cr-50079-FJIVI Document 28-3 Filed 05/23/2008 Page10f2

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IN LINSTED STAYES [fl MAGISTFIATE ij] oisrnlcr [1 APPEALS counr or [1 orrlen PANEL rspeelry below)
IN THE CASE OF LOCATIGN NUMBER
l...—.,...,........,.....,,..vs,.............,.,.._._.........
AT

oocxet uumeens
. PERSON HEPHESENTED {Show your iuli nam egggggndani _ Adult Magistrate
. 21;} Defendant-Juvenile
" 3 B Appellant District Court
tmfrobation Violator }
· 0 rl 1A l
CHARGE/OFFENSE (describe it applicable ii. elieeit box —~» I B F?;°"*' 5 [3 P°{°l° V'°|aI°r OU O mm S
_ ·<""') B Ml5d¤m¤5¤¤F 5 [Z] Habeas Petitioner
71] 2255 Petitioner
{ BH Material Witness
I QU Oti1er(Specify}

Are you now employed? III Yes EIN:} [I Am Seif Employed
Name and address of employer:
IF YES, how much do you IF NO, give month and year of last employment
EWIPLOY— earn per month? $ ______________________ How much did you earn per month? S
MEN? if married is our S ouse em Io ed? C] Yes E No
V
IF YES, how much does your It . minor under age 21, what is your Parents or
Spouse earn per month? $ _.......;,.. Guardians approximate montniy income? $..,...e.......
Have you received within the past 12 months any income from a business, profession or other form of se f—e pioyment, or in the
form of rent payments, interest, dividends, retirement or annuity payments, or other sources? [1 Yes No
RECEIVED SOURCES
A mggmg IF YES, GIVE THE AMOUNT r
SSETS RECEIVED at loerxrriry s _" , ~——--
TI-IE SOURCES 1...........,...........,...........J _,,_ ,,,,,,,
CASH Have you any cash on hand or money in savings or checking account [II Yes No IF YES, state total amount S ""'"r
Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary househoid
furnishings and clothing)? 1] Yes we
vALue DESCRIPHON
PROP- ....,__. _,....
IF YES, GEVETHE VALUEAND $l l
__ ERTY
DESCRIBE ET Ij..__...I '

l I I.............J
STATUS Jctalf List persons you actually support and your relationship to them
D. B
;____l SINGLE Dependents
DEPENDENTS l-l M»°·*iRl€¤
L........J WIDOWED ...,.,...._,,
l_______l SEPARATED OF?
OBLIGATIONS DIVDRCED

8* DEBTS DEBTS g, APAnrmem Creditors Total Debt Monthiy pay:.
MONTHLY Offffi ___,___,,. S 5;
BILLS ...........,,,,,,.." ......................
(LISTALL cneonons, ""“` " ` S ·~———·~·-~ S ""‘””
INCLUDING BANKS, _...-~———~ ________ —————————·—-~·—-—-—_ “““‘““““““...‘;““‘“"“'
Lolo: conemles, S ····~——· $
CHAFIGE Accounts, ...._e, ...-——-— ..._.
eral S $....,.;y........
1 certify under penalty ot perjury that the foregoing is true and correct. Executed on (date)
SIGNATURE OF DEFENDANT k gl { i
SE . I . i.·» - e , ‘ . ‘
Case 2:0438lB-S?Ii)S$°S$'—’FE.I°lIIl€ °I5Io[Ziu - · ¤ ...-e • we he ¤-e..¢¤.é*t3'- wif-

Case 2:04-cr-50079-FJM

Document 28-3

Filed 05/23/2008

Page 1 of 2

Case 2:04-cr-50079-FJM

Document 28-3

Filed 05/23/2008

Page 2 of 2