United States Child Support

FINANCIALAFFIDAVIT

IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT, OR OTHER SERVICES WITHOUT PAYMENT OF FEE ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY

INCOME

&

ASSETS

EMPLOYMENT

Do you have a job? Yes No

IF YES, how much do you earn per month? Will you still have a job after this arrest? Yes No Unknown PROPERTY

Do you own any of the following, and if so, what is it worth? APPROXIMATEVALUE DESCRIPTION&AMOUNTOWED

Home $ Car/Truck/Vehicle$ Boat $ Stocks/bonds $ Other property $ CASH

&

BANK

ACCOUNTS

Do you have any cash, or money in savings or checking accounts? Yes No IF YES, give the total approximate amount after monthly expenses $ CJA-23

(Rev 3/21)

IN THE UNITED STATES : DISTRICT COURT : COURT OF APPEALS : OTHER (Specify Below) IN THE CASE OF LOCATION

NUMBER

DOCKET NUMBERS

Magistrate Judge

District Court

Court of Appeals

V.

FOR

AT

PERSON REPRESENTED (Show your full name)

CHARGE/OFFENSE (Describe if applicable & check box ) : Felony

: Misdemeanor

1 : Defendant - Adult

2 : Defendant - Juvenile

3 : Appellant

4 : Probation Violator

5 : Supervised Release Violator

6 : Habeas Petitioner

7 : 2255 Petitioner

8 : Material Witness

9 : Other (Specify) OBLIGATIONS,

EXPENSES, &

DEBTS

How many people do you financially support? BILLS & DEBTS MONTHLYEXPENSE TOTALDEBT

Housing $ $

Groceries $ $

Medical expenses $ $ Utilities $ $

Credit cards $ $ Car/Truck/Vehicle $ $ Childcare $ $

Child support $ $ Insurance $ $

Loans $ $

Fines $ $

Other $ $

I certify under penalty of perjury that the foregoing is true and correct. SIGNATURE OF DEFENDANT Date

(OR PERSON SEEKING REPRESENTATION)

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