Financial Affidavit

**NOT FOR PUBLIC DISCLOSURE** (To be completed by ALL defendants) USDC - Western District of Michigan PERSONAL DATA / CASE INFORMATION USA v. Case Number Full Name Address CHARGE/OFFENSE (describe if applicable & check box) G Felony G Misdemeanor Phone ( FINANCIAL AFFIDAVIT ) (To be completed in support of request for attorney, expert or other court services without payment of fee) Are you now employed? G Yes G No G Am Self-Employed IF NO, give month and year of last employment How much did you earn per month? $ Name and address of employer: EMPLOYMENT IF YES, how much do you earn per month? $ If married is your Spouse employed? IF YES, how much does your Spouse earn per month? $ G Yes G No If a minor under age 21, what is your Parents or Guardian's approximate monthly income? $ Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? G Yes G No ASSETS OTHER INCOME RECEIVED SOURCES IF YES, GIVE THE AMOUNT RECEIVED & IDENTIFY THE SOURCES $ CASH Have you any cash on hand or money in savings or checking accts? G Yes G No IF YES, state total amount $ Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? PROPERTY 9 Yes 9 No VALUE DESCRIPTION IF YES, GIVE THE VALUE AND $ DESCRIBE IT MARITAL STATUS SINGLE MARRIED WIDOWED SEPARATED OR DIVORCED APARTMENT OR HOME: Total No. of Dependents List persons you actually support and your relationship to them DEPENDENTS OBLIGATIONS & DEBTS 9 9 Creditors $ $ DEBTS & MONTHLY BILLS (LIST ALL CREDITORS, INCLUDING BANKS, LOAN COMPANIES, CHARGE ACCOUNTS, ETC.) Total Debt $ $ $ $ Monthly Paymt. 9 $ $ I certify under penalty of perjury that the foregoing is true and correct. Executed on (date) SIGNATURE OF DEFENDANT (OR PERSON REPRESENTED) * G Form read to defendant in his/her native language and completed by the ( ) Interpreter ( ) Probation Officer. Rev. 11/06 American LegalNet, Inc. www.FormsWorkFlow.com