Free Affidavit - Florida

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

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1 2 3 4 5

PERSON REPRESENTED (Show your full name)

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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

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District Court Court of Appeals

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now

G Yes

G No

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

ASSETS

9

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? $

EMPLOYMENT

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

OTHER INCOME

IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES

$

CASH

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

G

Yes

G No

IF YES , state total amount

PROPERTY

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

IF YES, GIVE THE VALUE AND $ DESCRIBE IT

OBLIGATIONS & DEBTS

9

DEPENDENTS

9

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

Total No. of Dependants

9
Creditors

List persons you actually support and your relationship to them

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

9

Total Debt $ $ $ $ $ $ $ $

Monthly Paymt.

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

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