Fill and Sign the Cja 23 Financial Affidavit Form

IN UNITED STATES LOCATION NUMBER IN THE CASE Of: FOR VS AT D O C K E T N U M B E R S Magistrate District Court Court of Appeals Defendant - Adult 1 Defendant - Juvenile 2 3 Appellant 4 Probation Violator 5 Parole Violator FelonyMisdemeanor 6 Habeas Petitioner 7 2255 Petitioner 8 Material Witness 9 (Specify) No Are you now employed? YesAm Self Employed Name and address of employer: IF Y E S , how much do you IF N O , give month and year of last employment EMPLOY- earn per month? $ How much did you earn per month? $ MENT Yes If married is your Spouse employed? IF Y E S , how much does your No If a minor under age 21, what is your Parents orGuardian's approximate monthly income? $ Spouse earn per month? $ Have you received within the past 12 months any inc ome from a business, profession or other form of self-employment, or in theform of rent payments, interest, dividends, retirement or annuity payments, or other sources? Yes No R E C E IV E D S O U R C E S O T H E R IF Y E S , GIVE THE AMOUNT INCOME ASSETS RECEIVED & IDENTIFY $ THE SOURCES CASH Yes No IF YES, state total amount $ Have you any cash on hand or money in savings or ch ecking account Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household Yes Nofurnishings and clothing)? VALUE D E S C R IP T IO N PROP- IF YES, GIVE THE VALUE AND $ DESCRIBE IT ERTY MARITAL STATUS List persons you actually support and your relation ship to them TotalNo. of SINGLE Dependents MARRIED D E P E N D E N T S WIDOWED SEPARATED OR DIVORCED APARTMENT Creditors Total DebtMonthly Payt. DEBTS & OR HOME: MONTHLY $ $ BILLS $ $ (LIST ALL CREDITORS,INCLUDING BANKS, $ $ LOAN COMPANIESCHARGE ACCOUNTS, $ $ ETC. ) I certify under penalty of perjury that the foregoi ng is true and correct. Executed on (date) SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED) IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICE WITHOUT PAYMENT OF FEE FINANCIAL AFFIDAVIT CJA 23 (REV. 5/98) MAGISTRATE DISTRICT APPEALS COURT or OTHER PANEL (Specify below) PERSON REPRESENTED (Show your full name) CHARGE/OFFENSE (describe if applicable & check box - ) A N S W E R S T O Q U E S T IO N S R E G A R D IN G A B IL IT Y T O P A Y O B L IG A T IO N S & D E B T S