Form Cja 23 - Financial Affidavit
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1FINANCIAL AFFIDAVIT
CJA 23
(Rev. 11/11)
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)
LOCATION NUMBER
IN THE CASE OF
FOR
v.
AT
’
PERSON REPRESENTED
1
Defendant - Adult
DOCKET NUMBERS
(Show your full name)
’
Magistrate Judge
2
Defendant - Juvenile
’
Appellant
3
’
District Court
4
Probation Violator
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5
Supervised Release Violator
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5
Habeas Petitioner
Court of Appeals
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’
ÿ
CHARGE/OFFENSE
Felony
7
2255 Petitioner
(describe if applicable & check box
)
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’
Misdemeanor
8
Material Witness
’
9
Other
(Specify)
ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
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Are you now employed?
Yes
No
Self-Employed
Name and address of employer:
IF YES, how much do you
IF NO, give month and year of last employment?
earn per month? $
How much did you earn per month? $
EMPLOY-
MENT
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’
If married, is your spouse employed?
Yes
No
If you are a minor under age 21,
IF YES, how much does your
what is the approximate monthly income
spouse earn per month? $
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
INCOME
’
’
form of rent payments, interest, dividends, retirement or annuity payments, or other sources?
Yes
No
&
ASSETS
RECEIVED
SOURCES
OTHER
IF YES, give the amount
$
INCOME
received and identify the
$
sources
$
’
’
CASH
Do you have any cash on hand or money in savings or checking accounts?
Yes
No IF YES, total amount? $
Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings
’
’
and clothing)?
Yes
No
VALUE
DESCRIPTION
PROP-
IF YES, give value and
$
ERTY
description for each
$
$
$
MARITAL STATUS
List persons you actually support and your relationship to them
Single
Total
DEPENDENTS
Married
No. of
Widowed
Dependents
Separated or Divorced
OBLIGATIONS
&
MONTHLY
DEBTS
DESCRIPTION
TOTAL DEBT
PAYMENT
DEBTS &
$
$
MONTHLY BILLS
(Rent, utilities, loans,
$
$
charge accounts, etc.)
$
$
$
$
I certify under penalty of perjury that the foregoing is true and correct.
SIGNATURE OF DEFENDANT
Date
(OR PERSON REPRESENTED)
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