Free cja23.PDF - Missouri

FINANCIAL AFFIDAVIT
IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICE WITHOUT PAYMENT OF FEE IN UNITED STATES
IN THE CASE Of: VS

CJA 23 (REV. 5/98)

MAGISTRATE

DISTRICT
FOR

APPEALS COURT or

OTHER PANEL (Specify below)
LOCATION NUMBER

AT

DOCKET NUMBERS

PERSON REPRESENTED (Show your full name)

1 2 3 4 5

Defendant - Adult Defendant - Juvenile Appellant Probation Violator Parole Violator Habeas Petitioner 2255 Petitioner Material Witness (Specify)

Magistrate

District Court

Court of Appeals

CHARGE/OFFENSE (describe if applicable & check box - )

Felony Misdemeanor

6 7 8 9

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now employed? Yes 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: IF YES, how much do you EMPLOYearn per month? $ MENT If married is your Spouse employed? IF YES, how much does your Spouse earn per month? $

Yes

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? Yes No

ASSETS

OTHER INCOME

RECEIVED

SOURCES

IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY $ THE SOURCES
Have you any cash on hand or money in savings or checking account Yes No IF YES, state total amount $

CASH

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household Yes No furnishings and clothing)?

PROPERTY

VALUE

DESCRIPTION

IF YES, GIVE THE VALUE AND $ DESCRIBE IT

MARITAL STATUS SINGLE

Total No. of Dependents

List persons you actually support and your relationship to them

DEPENDENTS

MARRIED WIDOWED SEPARATED OR DIVORCED

OBLIGATIONS D E B T S & MONTHLY & DEBTS
BILLS
(LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES CHARGE ACCOUNTS, ETC. )

APARTMENT OR HOME:

Creditors

Total Debt

Monthly Payt.

$ $
$ $

$ $
$ $

I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)