Financial Affidavit {CJA 23}

CJA 23 (Rev. 11/11) FINANCIAL AFFIDAVIT IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT, OR OTHER SERVICES WITHOUT PAYMENT OF FEE IN THE UNITED STATES IN THE CASE OF ' DISTRICT COURT ' COURT OF APPEALS FOR ' OTHER (Specify below) LOCATION NUMBER v. AT PERSON REPRESENTED (Show your full name) 1 2 3 CHARGE/OFFENSE (describe if applicable & check boxÿ) ' Felony ' Misdemeanor 4 5 5 7 8 9 ' ' ' ' ' ' ' ' ' Defendant - Adult Defendant - Juvenile Appellant Probation Violator Supervised Release Violator Habeas Petitioner 2255 Petitioner Material Witness Other (Specify) DOCKET NUMBERS Magistrate Judge District Court Court of Appeals ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Are you now employed? Name and address of employer: IF YES, how much do you earn per month? $ IF NO, give month and year of last employment? How much did you earn per month? $ ' Yes ' No ' Self-Employed EMPLOYMENT If married, is your spouse employed? IF YES, how much does your spouse earn per month? $ INCOME & ASSETS ' Yes ' No If you are a minor under age 21, what is the approximate monthly income of your parent(s) or guardian(s)? $ 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 OTHER INCOME RECEIVED IF YES, give the amount received and identify the sources $ $ $ SOURCES CASH Do you have any cash on hand or money in savings or checking accounts? ' Yes ' No IF YES, total amount? $ PROPERTY Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? ' Yes ' No VALUE DESCRIPTION IF YES, give value and $ description for each $ $ $ MARITAL STATUS Single Married Widowed Separated or Divorced List persons you actually support and your relationship to them Total No. of Dependents MONTHLY PAYMENT $ $ $ $ DEPENDENTS OBLIGATIONS & DEBTS DEBTS & MONTHLY BILLS (Rent, utilities, loans, charge accounts, etc.) DESCRIPTION $ $ $ $ TOTAL DEBT I certify under penalty of perjury that the foregoing is true and correct. SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED) Date American LegalNet, Inc. www.FormsWorkFlow.com