CONFIDENTIAL CJA 23 (R ev. 4cca 3/12) FINANCIAL AFFIDAVIT IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT, OR OTHER SERVICES WITHOUT PAYMENT OF FEE IN THE UNITED STATES DISTRICT COURT IN THE C ASE O F COURT OF APPEALS FOR OTHER (Specify below) LOCATION NUMBER v. AT PERSON REPRESENTED (Show your full nam e) CHARGE/OFFENSE (describe if applicable & check box˙ ) Felony Misdemeanor 1 Defendant - Adult 2 Defendant - Juvenile 3 Appellant 4 Probation Violator 5 Supervised Release Violator 5 Habeas Petitioner 7 2255 Petitioner 8 Material Witness 9 Other (Specify) DOCKET NUMBERS M agistrate Judge D istrict C ourt C ourt of Appeals ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Are you now employed? Name and address of employer: IF YES, how much do you earn per month? $ EMPLOYMENT If married, is your spouse employed? IF YES, how much does your spouse earn per month? $ INCOME & ASSETS IF NO, give month and year of last employment? How much did you earn per month? $ Yes No Self-Employed Yes No If you are a minor under age 21, what is the approximate monthly income 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 form of rent payments, interest, dividends, retirement or annuity payments, or other sources? Yes No OTHER INCOME RECEIVED IF YES, give the amount received and identify the sources $ $ $ SOURCES CASH Do you have any cash on hand or money in savings or checking accounts? Yes No IF YES, total amount? $ PROPERTY 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 $ $ $ MARITAL STATUS Single Married Widowed Separated or Divorced List persons you actually support and your relationship to them Total No. of Dependents MONTHLY PAYMENT $ $ $ $ DEPENDENTS OBLIGATIONS & DEBTS DEBTS & MONTHLY BILLS (Rent, utilities, loans, charge accounts, etc.) DESCRIPTION $ $ $ $ TOTAL DEBT I certify under penalty of perjury that the foregoing is true and correct. SIGNATURE OF DEFENDANT (O R PERSO N REPRESEN TED ) Date Print Save As... Reset American LegalNet, Inc. www.FormsWorkFlow.com