Civil Appeal Information Form

UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT - SUPPLEMENT TO CJA FORM 23 - DEFENDANT'S FINANCIAL STATUS Instructions: Provide the requested information as fully as possible. Attach additional pages and explanations as necessary. Serve a copy of this form on the U.S. Attorney and defense counsel, if any, and return to this Court. Your CJA Form 23 cannot be processed without this additional information. Name: Caption: Court of Appeals No.: District Court No.: Total Assets: List all assets, including but not limited to the following: accounts, securities, real estate, life insurance, personal property, etc. Item Amount bank TOTAL ASSETS American LegalNet, Inc. www.USCourtForms.com SUPPLEMENT TO CJA FORM 23 PAGE 2 Total Liabilities: List all liabilities and unsecured debts, including but not limited to all mortgages, credit card balances, car loans, loans, etc. Item Amount TOTAL LIABILITIES AND UNSECURED DEBTS Networth: (Total Assets Minus Total Liabilities) Monthly Income: Include all taxable and non-taxable income, interest, dividends, etc. Item Amount TOTAL INCOME American LegalNet, Inc. www.USCourtForms.com SUPPLEMENT TO CJA FORM 23 PAGE 3 Monthly Expenses: Includes mortgages, rent, utilities, telephone, groceries, medical, clothing, installment payments. Item Mortgage/rent Utilities: Electric Heating oil/gas Water/sewer Telephone Groceries/supplies Insurance: Health Life Homeowners Other Amount Minimum installment payments (e.g., credit cards) Transportation Repair bills Medical Clothing Other TOTAL EXPENSES I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on , 19 . Signature (Under Penalty of Perjury, 28 U.S.C. §1746) American LegalNet, Inc. www.USCourtForms.com SUPPLEMENT TO CJA FORM 23 PAGE 4 REV. 7/93 American LegalNet, Inc. www.USCourtForms.com