Free CJA 23 - Financial Affidavit - Federal

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 employed?

G

Yes

G

No

G

Am Self-Employed
IF NO, give month and year of last employment How much did you earn per month? $

Name and address of employer:
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? $

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 form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No ASSETS

9

OTHER INCOME

RECEIVED

SOURCES

IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES

$

CASH

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

G

Yes

G 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 No

G

G

PROPERTY

VALUE

DESCRIPTION

IF YES, GIVE THE VALUE AND $ DESCRIBE IT

MARITAL STATUS SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME:

Total No. of Dependents

List persons you actually support and your relationship to them

DEPENDENTS

OBLIGATIONS & DEBTS

9

9
Creditors
$ $

9

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

Total Debt $
$ $ $

Monthly Paymt.

9

$ $

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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