OCJA 22 (9/76) APPOINTMENT OF COUNSEL UNDER THE CRIMINAL JUSTICE ACT UNITED STATES DISTRICT COURT for the Register No. U.S. Court Docket No. IN THE MATTER OF STATEMENT OF G (PAROLEE) G (MANDATORY RELEASEE) STATEMENT OF PAROLEE OR MANDATORY RELEASEE CONCERNING APPOINTMENT OF COUNSEL UNDER THE CRIMINAL JUSTICE ACT I, , having been fully advised of the charges against me and of my rights as set forth in the attached copy of the G Notice of Pending Dispositional Review G Warrant Application G Summons to Appear understand that I may apply to the United States District Court for appointment of counsel to assist or represent me in this matter before the United States Parole Commission, and that such representation by counsel will be furnished to me if the judicial officer determines I am financially unable to obtain attorney representation; Pursuant to such notification concerning appointment of counsel, I do not wish to apply to the District Court for appointment of counsel. 2. I do hereby apply to the District Court for appointment of counsel and in connection with this application I state as follows concerning my financial condition: 1. I am . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employed If employed, state weekly income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ If self-employed, state average weekly income . . . . . . . . . . . . . . . . . . . . . . . . . $ Cash on hand and in bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Number of dependants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Property owned: I certify the above to be correct. Unemployed (Signature of Applicant) Witness: Signature Title DATE: A false or dishonest answer to a question in this application may be punishable by fine or imprisonment or both, (18 U.S.C. § 1001). American LegalNet, Inc. www.FormsWorkflow.com