Expression, Financial Affidavit

• Court: United States Federal Court
• Legal Form Number: CJA 23
• Section: United States Federal Court

FINANCIAL AFFIDAVIT

IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT, OR OTHER SERVICES WITHOUT PAYMENT OF FEE

ANSWERS TO QUESTIONS REGARDING ABILITYTO 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?

APPROXIMATE VALUE 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 nancially support? ______

BILLS & DEBTS MONTHLY EXPENSE TOTAL DEBT

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)