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
&
ASSETS
EMPLOY-
MENT
Are 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
INCOME
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
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
’
No IF YES, total amount? $
PROP-
ERTY
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
$
$
$
$
OBLIGATIONS
&
DEBTS
DEPENDENTS
MARITAL STATUS
Total
No. of
Dependents
List 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 DEBT
MONTHLY
PAYMENT
$$
$$
$$
$$
I certify under penalty of perjury that the foregoing is true and correct.
SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)
Date
