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O CJA 23
Rev. 5/98 IN UN IT ED S TA TES IN THE CASE V.S. AT MAGISTRATE
FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATT ORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
DISTRICT FOR APP EALS COURT or OTHER PANEL (Specify below) LOCA TION NU M BER
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1 2 3 4 5 De fend ant --A dult De fend ant - J uve nile Ap p ellant Probation Violator Parole Violator Hab eas P etit ioner 225 5 P etit ioner M aterial Witness Ot her DOCK ET NU M BERS M agistrate
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PER SON REP RESENT ED ( Show y our full name)
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District Court Co urt of A p p eals
CH A RG E/ O F F EN SE (des cr ib e i f ap p li ca ble & c hec k box ΓΏ )
Felony M isdemeanor
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ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Are yo u no w empl o ye d? Ye s No Am Self-Employed
IF NO, give month and year of last employment How much did you earn per month? $
Name and address of employer:
EMPLO YMENT
IF YES, how much do you earn per month? $ If m arr ie d is yo ur Spo us e e mpl o ye d? IF YES, how much does your Spouse earn per month? $ Ye s
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 No Yes the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? ASSETS
OTHER INCOME RECEIVED S OURCES
IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES
$
Ye s N o IF Y ES , state total amoun t $
CAS H
Have yo u an y cas h on han d or money in sav ings or checking a ccou nts ?
Do you own any real estate, stocks, bonds , notes, automobiles, or other valuable property (excluding ordinary hous ehold furnish ings and clo th ing )? PROPERTY Ye s No VALUE DESCRIPTION
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OBLIGATIONS & DEBTS
IF YES, GIVE THE VALUE AND $ DESCRIBE IT
M ARITAL STATUS SINGLE M ARRIED WIDO WED SEPARATED OR DIVORCED APARTMENT OR HO M E:
Total No. of Dependents
List p ersons y ou act ually sup p ort and y our relationship to them
DEPENDENTS
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DEB TS & MONTHLY B ILLS
(L IST AL L CR ED IT O RS, IN CLU D IN G BA N K S, LO A N CO MP A N IE S, CH A RG E A CCO U N TS, ET C.)
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Creditors
$ $ $ $
Tot al Debt $
$ $ $
M onthly Paymt.
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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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