Free CJA 23 - Financial Affidavit - Georgia

CONFIDENTIAL
OCJA 23
Rev. 4CCA 11/04 IN THE CASE FOR

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

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 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 Yes No clothing)?

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

9
Creditors
$ $ $ $

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

Total Debt $
$ $ $

Monthly Paymt.

9
Executed on (date)

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)

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