CONFIDENTIAL FINANCIAL AFFIDAVIT OCJA 23 IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE IN UNITED STATES G MAGISTRATE G DISTRICT G APPEALS COURT or G OTHER PANEL (Specify below) Rev. 4CCA 11/04 IN THE CASE LOCATION NUMBER * FOR V.S. AT COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : PERSON REPRESENTED (Show your full name) 1 * 2 3 4 Plaintiff(s) CHARGE/OFFENSE (describe if applicable & check box ÿ) G Felony -againstG Misdemeanor 5 6 7 8 9 G G G G G G G G G Index No. Defendant—Adult DOCKET NUMBERS Magistrate Defendant - Juvenile : Calendar No. Appellant * District Court Probation Violator : JUDICIAL SUBPOENA Parole Violator Court of Appeals Habeas Petitioner : 2255 Petitioner Material Witness : Other : ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Defendant(s) Are .you. now . . . . . . . . . . .G .Yes. . . . . G. . No. . . . . . . .Am .Self-Employed G . . . . . . . .: . . . . . . . . employed? . . . . .. .. Name and address of employer: EMPLOYMENT IF YES, how much do you earn OF THE STATE THE PEOPLE per month? $ OF NEW YORK If married is your Spouse employed? TO IF YES, how much does your Spouse earn per month? $ G IF NO, give month and year of last employment How much did you earn per month? $ G Yes No If a minor under age 21, what is your Parents or Guardian’s approximate monthly 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 the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? GREETINGS: G Yes G No ASSETS 9 OTHER INCOME CASH RECEIVED SOURCES IF YES, GIVECOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE THE AMOUNT , the RECEIVED & IDENTIFY Honorable at the Court $ County of THE SOURCES located at in room , on the day of , 20 , at o'clock in the noon, and at any recessed G Yes G No IF YES, state total amount $ or adjourned date, to testify and give evidence as a witness in this action on the part of the Have you any cash on hand or money in savings or checking accounts? Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and Yes No clothing)? G PROPERTY VALUE Court in DEPENDENTS OBLIGATIONS & DEBTS 9 G DESCRIPTION Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to IF YES, GIVE THE behalf thisAND the party on whose VALUE subpoena was issued for a maximum penalty of $50 and all damages sustained as a DESCRIBE result of your failure to comply. IT $ DEBTS & MONTHLY BILLS (LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.) Witness, Honorable County, MARITAL STATUS 9 , one of the Justices of the day of SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME: 9 List persons you actually support and your relationship to them (Attorney must sign above and type name below) Total Debt Attorney(s) for Monthly Paymt. $ $ $ $ $ $ $ Office and P.O. Address I certify under penalty of perjury that the foregoing is true and correct. The information herein is protected from public disclosure by the Judicial Conference Policy on Public Access to Electronic Criminal Case Files. (OR PERSON REPRESENTED) , 20 Creditors 9 SIGNATURE OF DEFENDANT Total No. of Dependents * $ Executed on (date) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com