Financial Affidavit

Local CJA 23 (5/10) Financial Affidavit IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE Case Name_____________________________________________________ Case No. ________________________ Name of Defendant/Person Represented____________________________________________________________ DIRECTIONS: PLEASE ANSWER ALL OF THE QUESTIONS BELOW AND SIGN AND DATE THIS AFFIDAVIT. 1. Do you currently work? G No . . . . Date you last worked_______________________ Monthly income $_________ G Yes. . . . Name of employer_________________________ Monthly income $_________ G No . . . . Indicate marital status: G Single G Widowed G Separated or divorced G Yes . . . . How much does your spouse earn per month? $ ________________________ G No G Yes . . . . What is your parent or guardian's approximate monthly income? $__________ 2. Are you married? 3. Are you under age 21? 4. Do you have any money (in cash or bank accounts)? G No G Yes . . . . State total amount $_________ and location(s)__________________________ . . . . Please identify form of currency, if not U.S. funds________________________ 5. Do you own other valuable property such as a house, real estate, stocks, bonds, notes, or vehicles? G No G Yes . . . . Describe property and state its value: _________________________________ 6. Within the past 12 months have you received any income from any other source such as from self-employment, business, rent payments, interest, dividends, inheritance, retirement benefits, social security, or disability payments? G No G Yes . . . List amount received and identify source _______________________________ 7. List the people you financially support and their relationship to you: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 8. List the names of your creditors (people or companies you owe money to). State your monthly payments and the total amount you owe: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 9. I certify under penalty of perjury that all of the information I have provided above is true and correct. _________________________ Date ______________________________________________ Signature of Defendant/Person Represented FOR COURT USE ONLY Qualification__________ Partial Qualification__________ No Qualification__________ Date _________________ Judicial Officer's Initials________________ American LegalNet, Inc. www.FormsWorkFlow.com