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Date: March 24, 2008
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State: Federal
Category: Court Forms - Federal
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http://www.ca6.uscourts.gov/internet/forms/documents/CJA23affidavit.pdf

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CONFIDENTIAL
OCJA 23 Rev. 6CCA 05/23 IN THE CASE FOR

FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
MAGISTRATE DISTRICT APPEALS COURT or OTHER PANEL (Specify below) LOCATION NUMBER

IN UNITED STATES

V.S.
AT

*
1 2 3 4 5 Defendant--Adult Defendant - Juvenile Appellant Probation Violator Parole Violator Habeas Petitioner 2255 Petitioner Material Witness Other DOCKET NUMBERS Magistrate

PERSON REPRESENTED (Show your full name)

*
CHARGE/OFFENSE (describe if applicable & check box ) Felony Misdemeanor

*

District Court Court of Appeals

6 7 8 9

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now 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:
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

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 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

$
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 clothing)? Yes No 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

9
Creditors $ $ $ $ Total Debt $ $ $ $ Monthly Paymt.

9

DEBTS & 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. The information herein is protected from public disclosure by the Judicial Conference Policy on Public Access to Electronic Criminal Case Files SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED

Executed on (date)

*
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