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
*
1 2 3 4 5
PERSON REPRESENTED (Show your full name)
*
CHARGE/OFFENSE (describe if applicable & check box ΓΏ)
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 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 clothing)? Yes No
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
Creditors
$ $
9
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)
*
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CJA 23 - SCHEDULE A LIST OF INCOME AND DEBTS, BILLS AND EXPENSES NAME: INCOME Gross Monthly Income.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________ Less Deductions (Federal and State income tax withholdings, etc.). . . . . . . . . . . . . . $ -________ NET MONTHLY INCOME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________ TOTAL MONTHLY DEBTS, BILLS & EXPENSES (From Bottom Line Below). . . $ -_______ BALANCE (Disposable Income). . . . . $ ________
DEBTS, BILLS AND EXPENSES TOTAL ITEM DEBT Home Rent or Mortgage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________ Utilities: Electric. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Heating Oil/Gas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Water/Sewer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Telephone.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Groceries, supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Insurance: Auto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Health.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Homeowners/renters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Bank Loans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Credit Cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Transportation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Doctor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Dentist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Clothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Alimony/Child support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Day care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Court Fines.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________ Other ____________________. . . . . . . . . . . . . . . . . . . . . . . . . . . _________ ____________________. . . . . . . . . . . . . . . . . . . . . . . . . . . _________ ____________________. . . . . . . . . . . . . . . . . . . . . . . . . . . _________ TOTAL DEBTS, BILLS & EXPENSES $________ MONTHLY PAYMENT $ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ $_________