Free Financial affidavit for motion under 18 USC 3582(c)(2) - Michigan

**NOT FOR PUBLIC DISCLOSURE**
(To be completed by ALL defendants)

USDC - Western District of Michigan

PERSONAL DATA / CASE INFORMATION

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USA v.

Case Number

Full Name Address

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

Phone ( FINANCIAL AFFIDAVIT

)

(To be completed in support of request for attorney, expert or other court services without payment of fee)

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

ASSETS

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 accts?

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)? PROPERTY

9 Yes 9 No

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
$ $

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)

*

G Form read to defendant in his/her native language and completed by the

(

) Interpreter (

) Probation Officer.
Rev. 11/06