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Financial Affidavit

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CJA 23
(Rev. 11/11)	FINANCIAL AFFIDAVIT	
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)
IN THE CASE OF	LOCATION NUMBER
FOR
v.
AT
PERSON REPRESENTED	
  (Show your full name)	1’	Defendant - Adult DOCKET NUMBERS
2	
’	Defendant - Juvenile	Magistrate Judge
3	
’	Appellant
4	
’	Probation Violator	District Court	
5’	Supervised Release Violator
5	
’	Habeas Petitioner	Court of Appeals	
CHARGE/OFFENSE	 (describe if applicable & check box	ÿ)	’	Felony 7	’	2255 Petitioner	
’	Misdemeanor 8	’	Material Witness
9	
’	Other 	(Specify)	
ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
INCOME
&
ASSETSEMPLOY-
MENTAre 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?  $
If married, is your spouse employed?	
’	Yes	’	No
IF YES, how much does your
spouse earn per month?  $If you are a minor under age 21,
what is the approximate monthly income 
of your parent(s) or guardian(s)?  $
OTHER
INCOMEHave 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
RECEIVED SOURCES
IF YES, give the amount
received and identify the
sources$
$
$
CASH
Do you have any cash on hand or money in savings or checking accounts?	
’Yes	’	NoIF YES, total amount?  $
PROP-
ERTYDo 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$
$
$
$
OBLIGATIONS
& 
DEBTSDEPENDENTSMARITAL STATUS
Total
No. of
DependentsList persons you actually support and your relationship to them
Single
Married
Widowed
Separated or Divorced
DEBTS &
MONTHLY BILLS	
(Rent, utilities, loans,
charge accounts, etc.)	 DESCRIPTION TOTAL DEBTMONTHLY
PAYMENT
$$
$$
$$
$$
I certify under penalty of perjury that the foregoing is true and correct.  
SIGNATURE OF DEFENDANT	
(OR PERSON REPRESENTED)	Date
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