FINANCIAL 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 (Show your full name) 1 2 3 CHARGE/OFFENSE (describe if applicable & check boxÿ) 4 5 5 7 8 9 ’ Felony ’ Misdemeanor ’ ’ ’ ’ ’ ’ ’ ’ ’ Defendant - Adult Defendant - Juvenile Appellant Probation Violator Supervised Release Violator Habeas Petitioner 2255 Petitioner Material Witness Other (Specify) DOCKET NUMBERS Magistrate Judge District Court Court of Appeals ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY 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? $ EMPLOYMENT If married, is your spouse employed? ’ Yes ’ No If you are a minor under age 21, what is the approximate monthly income of your parent(s) or guardian(s)? $ IF YES, how much does your spouse earn per month? $ INCOME & ASSETS 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 CASH PROPERTY RECEIVED IF YES, give the amount received and identify the sources 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 IF YES, give value and $ description for each $ $ $ DEPENDENTS OBLIGATIONS & DEBTS SOURCES $ $ $ MARITAL STATUS Single Married Widowed Separated or Divorced DEBTS & MONTHLY BILLS (Rent, utilities, loans, charge accounts, etc.) List persons you actually support and your relationship to them Total No. of Dependents DESCRIPTION MONTHLY PAYMENT TOTAL DEBT $ $ $ $ $ $ $ $ I certify under penalty of perjury that the foregoing is true and correct. SIGNATURE OF DEFENDANT Date (OR PERSON REPRESENTED) American LegalNet, Inc. www.FormsWorkFlow.com