CONFIDENTIAL
OCJA 23
Rev. 4/05 IN THE CASE OF FOR
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
IN UNITED STATES
FINANCIAL AFFIDAVIT
G
APPEALS COURT or
G MAGISTRATE
G DISTRICT
G
OTHER PANEL (Specify below) LOCATION NUMBER
USA
V.S.
AT
*
1 2 3 4 5
PERSON REPRESENTED (Show your full name)
*
CHARGE/OFFENSE (describe if applicable & check box ΓΏ)
G G
Felony 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? Yes No
G
G
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 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
Reset Form
OBLIGATIONS & DEBTS
Print Form
9
DEPENDENTS
9
MARITAL STATUS SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME:
Total No. of Dependents
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 and Executed on (date) that 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)
*