Free Affidavit - District Court of Connecticut - Connecticut

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Case 3:00-cr-00167-DJ ‘ Document 307 Filed 05/1 1/2005 Page 1 of 1 .
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IN UNITED STATES EI MAG ISTRATE I] D TRICT I] APPEALS COURT or {9,,, rr, In ()'I`II·{`BiR #¤,•\,$IE]_, (spmry [mow)
IN THE CASE OF A a" . f' "_ it I, Location NUMBER
FOR I
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IM II/ni I I {M; -
PERSON REPRESEN TED [Show your full name) I F`? ultl DOCKET NUMBERS
» @©b\\ M\ 2 · - ‘ z lj; pétenaam .-itiienilc
3 I;] Appellant
4 IZLProbatinn Vie1aiu;»(¤,“Q“u Distrierfjrmrl
5 I] Parole Violator » " •· .
CH ARGE/OFFEN SE [describe if applicable & cheek box # I] Felony .5 [j Habcas pcmgnncr Court g{App(m|s
I] Misdemeaner 7 I] 2255 Petitioner
8 El Material Witness
9 El Other
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Are you new employed lf,] Yes No lj Am self-Employed
Name and address of e I- loyer:

EMPLOW IF YES, how much do u IF N0, give month and year oflast employment
MENT earn per mon ? $ I-low much did you earn per month? $

Ifmarried is your Spous employed? Q Yes I;} No
IF YES, how much doe your , Aka Ifa minor under age 21, whatis your Parents or
. Spouse earn per onth? $ Guardian’s approximate monthly income? $
Have you received within th past I2 months any income from a business, profession or other form of self-employment, r in the form
the form of rent payments, i ~ crest, dividends, retirement or annuity payments, or other sources? |:] Yes '%No
OTHER IIECEIVED SOURCES
ASSETS INCOME IF YES, GIVE THE A OUNT
RECEIVED & IDE TIFY $ __
T I-I E S O l RC E S
CASH Have you any cash on hand or ` ney in savings or checking accounts? I:] Yes Q No IF YES, state total amount $
Do you own any ical estate, st ks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and
clothing)? [I Yes Q •
PR0P_ VALUE DESCRIPTION
ERTY IF YES, GIVE THE VA UE AND $
DES RIBE IT


MARITAI. TATUS 1 Om] List persons you actually support and your r · tionship to them
No. of »-.. Lx
SIN LE Dependents LK O
DEPENDENTS .X.MA mw #2-
Wl I O W ED
SEP R ATED DR
oeucnrons & AM M13; TED C d
re itors ‘ Tot I Debt M thl P I.
DEBTS DEBTS & OR H0 .; 5 “ O DH y Sym
Moiwutv A I
- | Q x OG $ s
BILLS ;"’“;‘1
[LIS-; ALL .;;Rpm·mgg_ S —··1;··— $ ·· ·· ··
INCLUDING BANKS. $ $
LOAN COMPANIES, S '_"*;‘* S "_ "'*
CHARGE ACCOIJNTS. ,,, ____
BTC.)
I certify under penalty of perjury that the foregoing is true nd correct. Exeet3ted on (date) 5 2 I I
SIGNATURE OF DEFEN I · NT ’ - .
(OR PERSON REPRESE TED)
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