Free CJA 23 - Financial Affidavit - Federal


File Size: 637.6 kB
Pages: 1
Date: August 28, 2008
File Format: PDF
State: Federal
Category: Court Forms - Federal
Word Count: 334 Words, 2,228 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ca9.uscourts.gov/datastore/uploads/forms/CJA23affidavit.pdf

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CJA 23 Rev. 5/98

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

FINANCIAL AFFIDAVIT
DISTRICT FOR APPEALS COURT or

IN UNITED STATES
IN THE CASE

MAGISTRATE

OTHER PANEL (Specify below) LOCATION NUMBER

V.S.
AT


1 2
3

PERSON REPRESENTED (Show your full name)

Defendant-Adult Defendant - Juvenile
Appellant


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

DOCKET NUMBERS Magistrate

4
5 6 7 8

Probation Violator
Parole Violator Habeas Petitioner 2255 Petitioner Material Witness Other



District Court Court of Appeals

9

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now employed?
EMPLOYMENT

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: 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 a minor under age 21, what is your Parents or Guardian's approximate monthly income? $

No

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? Yes No
OTHER INCOME CASH PROPERTY

ASSETS



IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES

$ $ $

RECEIVED

SOURCES

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 No
VALUE DESCRIPTION

IF YES, GIVE THE VALUE AND $ DESCRIBE IT $ $ $
MARITAL STATUS SINGLE Total No. of Dependents List persons you actually support and your relationship to them

DEPENDENTS

OBLIGATIONS & DEBTS



MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME:


Creditors Total Debt Monthly Paymt.



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

$ $ $ $ Executed on (date)

$ $ $ $

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