Fill and Sign the Form Cja 23 Download Fillable PDF Financial Affidavit

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 ’ DISTRICT COURT ’ COURT OF APPEALS ’ OTHER (Specify below) IN THE CASE OF LOCATION NUMBER FOR v. AT PERSON REPRESENTED (Show your full name) 1’ Defendant - Adult DOCKET NUMBERS 2 ’ Defendant - Juvenile Magistrate Judge 3 ’ Appellant 4 ’ Probation Violator District Court 5’ Supervised Release Violator 5 ’ Habeas Petitioner Court of Appeals CHARGE/OFFENSE (describe if applicable & check box ÿ) ’ Felony 7 ’ 2255 Petitioner ’ Misdemeanor 8 ’ Material Witness 9 ’ Other (Specify) ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY INCOME & ASSETSEMPLOY- MENTAre you now employed? ’ Yes ’ No ’ Self-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? $ If married, is your spouse employed? ’ Yes ’ No IF YES, how much does your spouse earn per month? $If you are a minor under age 21, what is the approximate monthly income of your parent(s) or guardian(s)? $ OTHER INCOMEHave 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 RECEIVED SOURCES IF YES, give the amount received and identify the sources$ $ $ CASH Do you have any cash on hand or money in savings or checking accounts? ’Yes ’ NoIF YES, total amount? $ PROP- ERTYDo 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$ $ $ $ OBLIGATIONS & DEBTSDEPENDENTSMARITAL STATUS Total No. of DependentsList persons you actually support and your relationship to them Single Married Widowed Separated or Divorced DEBTS & MONTHLY BILLS (Rent, utilities, loans, charge accounts, etc.) DESCRIPTION TOTAL DEBTMONTHLY PAYMENT $$ $$ $$ $$ I certify under penalty of perjury that the foregoing is true and correct. SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED) Date