**NOT FOR PUBLIC DISCLOSURE** USDC - Western District of Michigan PERSONAL DATA / CASE INFORMATION (To be completed by ALL defendants) USA v. Case Number Full Name CHARGE/OFFENSE (describe if applicable & check box) G Felony G Misdemeanor Address Phone ( ) FINANCIAL AFFIDAVIT (To be completed in support of request for attorney, expert or other court services without payment of fee) Are you now employed? G Yes G No G Am Self-Employed Name and address of employer: EMPLOYMENT 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? IF YES, how much does your Spouse earn per month? $ G Yes G 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 the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No ASSETS OTHER INCOME CASH RECEIVED IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES SOURCES $ G Have you any cash on hand or money in savings or checking accts? Yes G No IF YES, state total amount $ Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings 9 Yes 9 No and clothing)? PROPERTY VALUE MARITAL STATUS DEPENDENTS OBLIGATIONS & DEBTS DESCRIPTION IF YES, GIVE THE VALUE AND $ DESCRIBE IT 9 APARTMENT OR HOME: DEBTS & MONTHLY BILLS (LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.) SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED List persons you actually support and your relationship to them Total No. of Dependents 9 Creditors Total Debt Monthly Paymt. $ $ $ $ $ 9 $ $ $ I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED) * G Form read to defendant in his/her native language and completed by the ( ) Interpreter ( ) Probation Officer. Rev. 11/06 American LegalNet, Inc. www.FormsWorkFlow.com